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Serial transverse enteroplasty to facilitate enteral autonomy in selected children with short bowel syndrome. BJS 2014; 101: 1329-1333.

Published: 14th July 2014

Authors: T. Wester, H. Borg, H. Naji, P. Stenström, G. Westbacke, H. E. Lilja et al.

Background

Serial transverse enteroplasty (STEP) was first described in 2003 as a method for lengthening and tapering of the bowel in short bowel syndrome. The aim of this multicentre study was to review the outcome of a Swedish cohort of children who underwent STEP.

Method

All children who had a STEP procedure at one of the four centres of paediatric surgery in Sweden between September 2005 and January 2013 were included in this observational cohort study. Demographic details, and data from the time of STEP and at follow‐up were collected from the case records and analysed.

Results

Twelve patients had a total of 16 STEP procedures; four children underwent a second STEP. The first STEP was performed at a median age of 5·8 (range 0·9–19·0) months. There was no death at a median follow‐up of 37·2 (range 3·0–87·5) months and no child had small bowel transplantation. Seven of the 12 children were weaned from parenteral nutrition at a median of 19·5 (range 2·3–42·9) months after STEP.

Conclusion

STEP is a useful procedure for selected patients with short bowel syndrome and seems to facilitate weaning from parenteral nutrition. At mid‐term follow‐up a majority of the children had achieved enteral autonomy. The study is limited by the small sample size and lack of a control group.

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2 Comments

Kirsty McFarlane

3 years ago

Sir,

I read with interest the article by Wester and colleagues about the serial transverse enteroplasty (STEP) procedure to facilitate enteral autonomy in children with short bowel syndrome. Although I concur with the authors that their study is limited by small sample size (n=12), more importantly the lack of a control group does not justify their conclusion that STEP seems to facilitate weaning from parenteral nutrition.

In this study total small bowel length was 45 cm before STEP. In a recent study by Fallon et al., however, patients with small intestine of at least 50 cm had a cumulative probability of weaning from PN of 96% after 24 months (1). In this report, intestinal lengthening was found to significantly lower the probability of achieving enteral autonomy, with 29% of patients weaned compared with 86% who did not undergo the lengthening procedure. In addition, intestinal lengthening was shown to prolong the duration of PN. In their study 78% of patients achieved enteral autonomy, including approximately one-third with a small intestinal length of no more than 30 cm. As a majority of patients with short bowel syndrome will achieve full enteral autonomy despite short intestinal length, these results warrant caution against surgical lengthening procedures.

V.E. de Meijer
Department of Surgery
Erasmus MC – University Medical Center Rotterdam
Rotterda
The Netherlands
v.demeijer@erasmusmc.nl

References:
1. Fallon EM, Mitchell PD, Nehra D, Potemkin AK, O’Loughlin AA, Gura KM, Puder M. Neonates with short bowel syndrome: an optimistic future for parenteral nutrition independence. JAMA Surg 2014; 149: 663-670.

Kirsty McFarlane

3 years ago

Sir,

We would like to thank Dr de Meijer for the comments. We have emphasized that the small sample size and the lack of control data are important limitations to our study. In a retrospective multicentre study, including 144 infants with a small bowel length of 41 cm, the cumulative incidence of enteral autonomy, death, and intestinal transplantation were 47%, 27%, and 26%, respectively (1). De Meijer quotes a retrospective single-centre study including 63 patients (2), where the cumulative probability to be weaned off parenteral nutrition was 71%; 13% died and 6% underwent small bowel transplantation. In our study 58% were weaned off parenteral nutrition at the median age of 19.5 months. Almost all our patients (11 of 12) had small bowel atresia. These patients usually have a very dilated small bowel with inefficient propulsive peristalsis that may result in bacterial overgrowth with impaired enteral absorption, prolonged duration of parenteral nutrition, and the risk of intestinal failure-associated liver disease. An important purpose with bowel lengthening procedures is to reduce the diameter to reduce the risk of bacterial overgrowth. Fallon and colleagues do not mention bowel dilatation (2). It is obvious that the population of children with intestinal failure is very heterogeneous. It is difficult to know which patients actually benefit from intestinal lengthening and tapering procedures, as pointed out by Javid and colleagues (3). There is a need for prospective multicentre randomized controlled trials, as there is a large variation in the incidence of enteral autonomy, mortality, and transplantation between different recent reports.

T Wester
H Borg
H Naji
P Stenströn
G Westbacke
HE Lilja

Department of Paediatric Surgery
Karolinska University Hospital
Solna
SE-171 76 Stockholm
Sweden
tomas.wester@karolinska.se

References:
1. Squires RH, Duggan C, Teitelbaum DH, Wales PW, Balint J, Venick R et al. Pediatric Intestinal Failure Consortium. Natural history of pediatric intestinal failure: initial report from the Pediatric Intestinal Failure Consortium. J Pediatr 2012; 161: 723-728.
2. Fallon EM, Mitchell PD, Nehra D, Potemkin AK, O’Loughlin AA, Gura KM, Puder M. Neonates with short bowel syndrome: an optimistic future for parenteral nutrition independence. JAMA Surg 2014; 149: 663-670.
3. Javid PJ, Sanchez SE, Horslen SP, Healey PJ. Intestinal lengthening and nutritional outcomes in children with short bowel syndrome. Am J Surg 2013; 205: 576-580.