Intestinal failure (IF), including surgical short bowel syndrome (SBS), is a life-threatening condition that is associated with several major medical complications as well as limitations in quality of life. The evolution of treatment strategies for IF/SBS has seen significant changes in the past 30 years. Like several major advances in surgery, the discovery of anastomotic techniques by Alexis Carrel in the early 1900s paved the way for intestinal transplantation (ITx). As a parallel to surgical discoveries, the development and implementation of parenteral nutrition (PN) and hormonal analogs has allowed clinicians to support IF patients and bridge them toward the ultimate therapy of ITx. The purpose of this chapter is to provide an overview of the causes and medical management of IF/SBS, indications for and various surgical techniques within ITx. The chapter reviews the landmark developments in surgical therapy techniques and provides an outline for the different technical variations within ITx.
The evolution in the medical management of IF/SBS has relied heavily on the advent of PN. Prior to 1968, patients who suffered a massive infarction of their small intestine were often left unresected at the time of laparotomy due to the lack of intravenous nutritional support in the perioperative setting.1 This often led to consecutive operations for resections of necrotic bowel and patients would ultimately succumb to sepsis and multiorgan failure. The first major breakthrough for PN was ushered in as an alternative therapy for the IF patient in 1968. Wilmore and colleagues were able to demonstrate that the infusion of a hypertonic nutrient solution through a dedicated central venous catheter (CVC) could deliver all of the necessary nutrients to sustain growth and development in an infant with intestinal atresia and IF/SBS.2 This development was a major stepping stone that paved the way for the surgical developments that followed.
Richard Lillehei and Thomas Starzl established the early techniques of ITx in canine models in the 1950-1960s.3,4 However, the first reports of ITx came in the mid-1980s when Williams, Starzl, and others documented the first successful isolated intestine, multivisceral, and liver-intestine transplants in humans.5–8 Together, these landmark medical and surgical establishments set the groundwork for the modern era of ITx.
PATHOPHYSIOLOGY OF INTESTINAL FAILURE AND ADAPTATION
The complex mechanisms and relationships of the neurohormonal, enteric nervous, and immune systems of the intestine are beyond the scope of this chapter. However, it must be noted that IF/SGS results from an inadequate delivery of micronutrients, fluid, and electrolytes via the gastrointestinal tract. In the IF/SBS patient, compensatory mechanisms of adaptation can be achieved in the remnant bowel in an attempt to restore the threshold for nutrient delivery.9–11 Clinically, the cornerstone of successful adaptation relies upon enterocyte mass. Likewise, patients with a greater length of functional bowel and the presence of an ileocecal valve (ICV) are likely to succeed at achieving ...