If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
We present a case of an adult who underwent this procedure including the results of long-term clinical and radiologic follow-up.
Case report
In March 1989, a 43-year-old obese woman underwent massive intestinal resection for acute mesenteric infarction. It was necessary to resect all of the small bowel from a point 25 cm beyond the ligament of Treitz to the mid transverse colon. Her postoperative course was complicated by abdominal pain, vomiting, and diarrhea (7 to 10 liquid stools per day); total parenteral nutrition (TPN) was instituted. Over the ensuing months, various oral feedings were attempted, none of which could be tolerated. She required long-term hospitalization for TPN and had recurrent episodes of catheter septicemia. An episode of acute acalculous cholecystitis required cholecystostomy.
Sixteen months after initial surgery, the patient's diarrhea was unchanged, and she was tolerating only 15% of her caloric requirement orally. Her body weight had dropped markedly from a preoperative level of 70 kg to 32 kg. She could not maintain body weight without supplemental intravenous nutrition for longer than 2 to 3 weeks. Contrast medium upper gastrointestinal (UGI) study revealed marked dilatation of the remaining small bowel with ineffective peristalsis (Fig l, A).
Fig. 1Preoperative (A) and postoperative UGI series. B, 3 months, (C) 30 months, and (D) 72 months after the operation. Intestinal transit time increased from less than 5 minutes (B) to 20 minutes (C) and only 10 minutes (D) .
In an attempt to improve intestinal absorption function, the patient underwent operation in August 1990. At this time, the small bowel measured 7 cm in diameter and was 38 cm long, indicating a 13 cm spontaneous elongation during the 16-month postoperative period. The jejunocolic anastomosis was widely patent. The isoperistaltic intestinal lengthening procedure, as described by Bianchi,
was performed to longitudinally divide the dilated small bowel with tapering and lengthening of the bowel loops by 35 cm (Fig 2).
Fig. 2Description and illustration of procedure of intestinal tapering and lengthening. A, Bowel is transected at previous anastomotic site of jejunocolostomy. B, Leaves of mesentery are separated, directing alternate vessels to either side of bowel wall, and relatively avascular plane is developed. C, Lower anvil of 5 cm GIA stapler is advanced into mesenteric space with aid of a Penrose drain. D, E, Intestine is transected longitudinally with stapler. F, Transection of bowel is repeated in retrograde fashion for 35 cm, and resulting parallel segments undergo isoperistaltic intestinal anastomosis in end-to-end fashion.
Three weeks later, the patient regained her appetite and began fluid intake. A low-fat diet was started at 4 weeks postoperatively. Gradually, regular enteral feeding was reinstituted over the next 3 months. The patient was then weaned from TPN over a 2-week period and discharged from the hospital at 4 months postoperatively. During the next 2 years, the patient had 4 short readmissions for supplemental parenteral nutrition. She continues to do well 7 years after the lengthening procedure, with no dietary problems and only 2 to 4 soft bowel movements per day. Her body weight is now a healthy 52 kg, and she performs her own housework without difficulty.
The functional changes in the UGI tract of our patient after this procedure are illustrated by a series of roentgenograms (Fig l , B-D). The small intestinal series made in the third postoperative month showed that the remnant jejunum was lengthened and had a normal diameter with effective peristalsis. Subsequent roentgenographic studies, performed 30 and 72 months later, showed slowly progressive dilatation of the lengthened loops with continuous presence of a radiologically verifiable peristalsis.
Discussion
The intestinal tapering and lengthening procedure performed in our patient was first described experimentally in pigs by Bianchi in 1980.
The technique can be performed because of the anatomic division of the intestinal vasculature within 2 leaves of mesentery. By longitudinally dividing the intestine between the 2 mesentery leaves, it can be separated into 2 parallel lumens with their own vascularity. Because this procedure preserves all mucosa by doubling the intestinal length and corrects the ineffective peristalsis by tapering the dilated intestine, it may be indicated in cases of short-bowel syndrome where the intestine is not only shortened but also dilated as part of the adaptation process.
According to the review of Shanbhogue and Molenaar,
at least 38 children have been treated with this procedure, and nutritional status improved in 71% of these patients. Remarkably, only 2 adult cases have been reported in the literature,
and one of them had a 17 cm remnant small bowel after ligation of the superior mesenteric artery. Her jejunum was lengthened by 33 cm during the procedure, and her enteral intake increased from 0% to 60% of caloric requirements.
Follow-up with UGI barium meal studies was sufficiently long in our patient to ensure that effective isoperistalsis will continue in these lengthened intestinal segments. This long-term effect is due primarily to the slow progressive dilatation of the luminal diameter and the absence of recurrent dilatation to the initial level that was observed throughout the 72-month follow-up period. Long after provision for increased bowel length, there was still insufficient hypertrophy of the intestinal villi to prove the mechanism of “enhanced adaptation response” as supposed by Bianchi.
its effect in our patient was limited and inconstant.
The technique involved in this procedure is demanding and may be associated with procedure-related complications such as ischemic necrosis of intestinal loops, anastomotic leakage, fistula formation, and intestinal obstruction. No such complications were observed in this case.
In performing this procedure, many technical points deserve special attention. First, it is necessary to perform meticulous manipulation during longitudinal division of the mesenteric border with preservation of the vasculature in the intestinal loops. The use of a Penrose drain facilitates the advancement of the anvil of the gastrointestinal anastomosis stapler between the mesentery, without injury to the vessels.
Second, if the vessel space is adequate, use of a stapler in division and anastomosis will minimize the blood loss and the possibility of leakage of the long suture line. Third, to avoid tension on the afferent vessels and make anastomosis easier, these parallel lengthened segments should be properly positioned in a spiral or helical pattern.
The duration of adaptation after massive bowel resection usually lasts for more than 1 year. After this period of adaptation, the remnant intestine may undergo luminal dilatation. To use a stapler to perform the longitudinal intestinal division, the diameter must be at least 4 cm5 to avoid compromising luminal patency.
We believe that this procedure has favorably modified the clinical course of this adult and that it may be useful in selected adult patients with short-bowel syndrome.
References
Bianchi A
Intestinal lengthening: an experimental and clinical review.
70299-0&id=gr1.jpg){kind=link}
70299-0&id=gr2.jpg){kind=link}