Comparison of supramesenteric aortic cross-clamping with supraceliac aortic cross-clamping for aortic reconstruction.

OBJECTIVE: Supraceliac aortic cross-clamping (SCXC) is routinely used during open aortic reconstruction (OAR) of pararenal aortic disease when suprarenal control is not feasible. On occasion, however, aortic control may be obtained at the supramesenteric level by supramesenteric cross-clamping (SMXC) between the superior mesenteric artery and the celiac axis. The purpose of this study was to compare outcomes between patients who had SMXC vs SCXC during OAR for both aneurysmal and occlusive diseases. METHODS: A retrospective chart review identified 69 patients who underwent elective OAR requiring SMXC (n = 18) or SCXC (n = 51). All patients with thoracoabdominal aneurysms and those who had inframesenteric (suprarenal and infrarenal) aortic control were excluded. Propensity score-based matching was performed to adjust for confounding factors in a 1:1 ratio to compare outcomes. Late survival was estimated by Kaplan-Meier methods. RESULTS: Propensity score-based matching was performed at a 1:1 ratio; 18 SMXC cases were matched with 18 SCXC cases. The average age was 66.7 years, and men constituted 72%. Baseline characteristics were matched, except for the incidence of peripheral vascular occlusive disease (72.2% in the SMXC group vs 33.3% in the SCXC group; P = .04). A majority (80.6%) of patients underwent OAR for aneurysmal disease (72.2% in the SMXC group, 88.9% in the SCXC group). Intraoperatively, there were no differences in operative times (325 minutes for SMXC vs 298 minutes for SCXC; P = .48), but the SMXC group had a longer renal ischemia time (40 minutes vs 28 minutes; P = .03). There were no significant differences in intraoperative blood loss (2.4 L vs 1.6 L; P = .2) or blood product transfusion requirements (packed red blood cells, 2.2 units vs 1.6 units [P = .5]; Cell Saver, 1.3 L vs 0.7 L [P = .09]). Overall complication rates did not differ significantly (27.8% for SMXC vs 44.4% for SCXC; P = .24). Thirty-day mortality rates did not differ between the two groups (0% for SMXC vs 5.6% for SCXC; P = 1). CONCLUSIONS: In this study, there were no differences in early morbidity or mortality between SMXC and SCXC during aortic reconstruction. SMXC, however, can be performed safely and effectively in properly selected patients. A larger, multicenter prospective study would help elucidate the potential benefits.

Report of 111 consecutive patients enrolled in the International Serial Transverse Enteroplasty (STEP) Data Registry: a retrospective observational study.

BACKGROUND: The International Serial Transverse Enteroplasty (STEP) Data Registry is a voluntary online database created in 2004 to collect information on patients undergoing the STEP procedure. The aim of this study was to identify preoperative factors that are significantly associated with transplantation or death or attainment of enteral autonomy after STEP. STUDY DESIGN: Data were collected from September 2004 to January 2010. Univariate and multivariate logistic regression analyses were applied to determine the predictors of transplantation or death or enteral autonomy post-STEP. Time to reach full enteral nutrition was estimated using a Kaplan-Meier curve. RESULTS: Fourteen of the 111 patients in the Registry were excluded due to inadequate follow-up. Of the remaining 97 patients, 11 patients died and 5 progressed to intestinal transplantation. On multivariate analysis, higher direct bilirubin and shorter pre-STEP bowel length were independently predictive of progression to transplantation or death (p = 0.05 and p < 0.001, respectively). Of the 78 patients who were 7 days of age or older and required parenteral nutrition at the time of STEP, 37 (47%) achieved enteral autonomy after the first STEP. Longer pre-STEP bowel length was also independently associated with enteral autonomy (p = 0.002). Median time to reach enteral autonomy based on Kaplan-Meier analysis was 21 months (95% CI, 12-30). CONCLUSIONS: Overall mortality post-STEP was 11%. Pre-STEP risk factors for progressing to transplantation or death were higher direct bilirubin and shorter bowel length. Among patients who underwent STEP for short bowel syndrome, 47% attained full enteral nutrition post-STEP. Patients with longer pre-STEP bowel length were significantly more likely to achieve enteral autonomy.

The impact of body mass index on perioperative outcomes of open and endovascular abdominal aortic aneurysm repair from the National Surgical Quality Improvement Program, 2005-2007.

OBJECTIVES: Obesity and morbid obesity have been shown to increase wound infections and occasionally mortality after many surgical procedures. Little is known about the relative impact of body mass index (BMI) on these outcomes after open (OAR) and endovascular abdominal aortic aneurysm repair (EVAR). METHODS: The 2005-2007 National Surgical Quality Improvement Program (NSQIP), a multi-institutional risk-adjusted database, was retrospectively queried to compare perioperative mortality (in-hospital or 30-day) and postoperative wound infections after OAR and EVAR. Patient demographics, comorbidities, and operative details were analyzed. Obesity was defined as a BMI >30 kg/m(2) and morbid obesity as a BMI >40 kg/m(2). Outcomes were compared with t test, Wilcoxon rank sum, χ(2), and multivariate logistic regression. RESULTS: There were 2097 OARs and 3358 EVARs. Compared with EVAR, OAR patients were younger, more likely to be women (26% vs 17%, P < .001), and less obese (27% vs 32%, P < .001). Mortality was 3.7% after OAR vs 1.2% after EVAR (risk ratio, 3.1; P < .001), and overall morbidity was 28% vs 12%, respectively (relative risk, 2.3; P < .001). Morbidly obese patients had a higher mortality for both OAR (7.3%) and EVAR (2.4%) than obese patients (3.9% OAR; 1.5% EVAR) or nonobese patients (3.7% OAR; 1.1% EVAR). Obese patients had a higher rate of wound infection vs nonobese after OAR (6.3% vs 2.4%, P < .001) and EVAR (3.3% vs 1.5%, P < .001). Morbid obesity predicted death after OAR but not after EVAR, and obesity was an independent predictor of wound infection after OAR and EVAR. CONCLUSIONS: Morbid obesity confers a worse outcome for death after abdominal aortic aneurysm repair. Obesity is also a risk factor for infectious complications after OAR and EVAR. Obese patients and, particularly, morbidly obese patients should be treated with EVAR when anatomically feasible.

Relationship between serum citrulline levels and progression to parenteral nutrition independence in children with short bowel syndrome.

OBJECTIVE: Although bowel length is an important prognostic variable used in the management of children with short bowel syndrome (SBS), reliable measurements can be difficult to obtain. Plasma citrulline (CIT) levels have been proposed as surrogate markers for bowel length and function. We sought to evaluate the relationship between CIT and parenteral nutrition (PN) independence in children with SBS. STUDY DESIGN: A retrospective chart review performed for all patients seen in a multidisciplinary pediatric intestinal rehabilitation clinic with a recorded CIT between January 2005 and December 2007 (n = 27). RESULTS: Median age at time of CIT determination was 2.4 years. Diagnoses included necrotizing enterocolitis (26%), intestinal atresias (19%), and gastroschisis (22%). Citrulline levels correlated well with bowel length (R = 0.73; P < .0001) and was a strong predictor of PN independence (P Wilcoxon = 0.002; area under the receiver operating characteristic curve = 0.88; 95% confidence interval, 0.75-1.00). The optimal CIT cutoff point distinguishing patients who reached PN independence was 15 micromol/L (sensitivity = 89%; specificity = 78%). CONCLUSION: Plasma CIT levels are strong predictors of PN independence in children with SBS and correlate well with a patient's recorded bowel length. A cutoff CIT level of 15 micromol/L may serve as a prognostic measure in counseling patients regarding the likelihood of future PN independence.

Long-term nutritional and clinical outcomes after serial transverse enteroplasty at a single institution.

PURPOSE: Serial transverse enteroplasty (STEP) is a novel technique to lengthen and taper bowel in patients with intestinal failure. First described in 2003, initial data and reports have demonstrated favorable short-term outcomes, but there is limited published data on long-term outcomes of the procedure. Our aim was to assess clinical and nutritional outcomes after the STEP procedure. METHODS: After obtaining institutional review board approval, we reviewed all records of patients (n = 16) who underwent the STEP procedure at our institution from February 2002 to February 2008. Patients were observed for a median time of 23 months (range, 1-71) postoperatively. Analyses of z scores for weight, height, and weight-for-height, and progression of enteral calories were performed using longitudinal linear models with random effects. RESULTS: Of the 16 patients (10 male), the median age at time of surgery was 12 months (interquartile range, 1.5-65.0). The mean increase in bowel length was 91% +/- 38%. After the STEP procedure, patients had increased weight-for-age z scores of 0.03 units per month (P = .0001), height for age z scores of 0.02 units per month (P = .004), and weight-for-height z scores of 0.04 units per month (P = .02). Patients had improved enteral tolerance of 1.4% per month (P < .0001). Six patients (38%) transitioned off parenteral nutrition (median, 248 days). Long-term complications included catheter-related bacteremia (n = 5), gastrointestinal bleeding (n = 3), and small bowel obstruction (n = 1). Two patients ultimately underwent transplantation. There were no deaths. CONCLUSIONS: In pediatric patients with intestinal failure, the STEP procedure improves enteral tolerance, results in significant catch-up growth, and is not associated with increased mortality.

Preservation of intestinal motility after the serial transverse enteroplasty procedure in a large animal model of short bowel syndrome.

INTRODUCTION: Serial transverse enteroplasty (STEP) has been shown to improve bowel function in short bowel syndrome. The effect of the STEP procedure on intestinal motility is not known, but some have hypothesized that it could disrupt bowel innervation and thus impair intestinal motility. METHODS: Growing Yorkshire pigs (n = 7) underwent 3 operations at 6-week intervals: (1) reversal of 50 cm of jejunum, (2) 90% bowel resection +/- STEP to the proximal dilated bowel (4 STEP, 3 control), and (3) implantation of serosal strain gauges. At each operation, baseline and post-octreotide small intestinal motility was studied with continuously perfused manometry catheters using non-anticholinergic anesthesia. In addition, awake monitoring was performed using strain gauge analysis 1 week after the third operation. Characteristics of phase III of the migrating motor complex (MMC) were compared between and within groups using t test, chi(2), and analysis of variance, with significance set at P < .05. RESULTS: Manometry data from the third surgery revealed no differences between groups or compared with baseline within groups for the presence and characteristics of phase III of the MMC. Specifically, the mean amplitude and frequency of phase III after octreotide, and both the mean baseline and mean octreotide-stimulated motility indices were equivalent. The duration of phase III after octreotide stimulation was significantly increased in the STEP animals, suggesting a potential benefit of the STEP procedure. Strain gauge analysis, performed in awake animals, confirmed no differences between the groups for basal and octreotide-stimulated characteristics of phase III of the MMC. CONCLUSIONS: These preliminary data suggest that the STEP procedure in a porcine model of short bowel syndrome does not interfere with baseline or hormonally stimulated motility within the small bowel. These findings further support the STEP procedure as a safe option for the surgical management of short bowel syndrome.

High diagnostic yield of gastrointestinal endoscopy in children with intestinal failure.

PURPOSE: Children with intestinal failure (IF) often have gastrointestinal (GI) symptoms, including bleeding, increased stool output, and feeding intolerance. The use of endoscopic assessment of these symptoms has not been previously reported. This report evaluates the diagnostic yield of GI endoscopy in the setting of IF. METHODS: After institutional review board approval, we reviewed the medical records (including endoscopy, pathology and microbiology data) of patients with IF who underwent GI endoscopies between September 1999 and March 2007. RESULTS: Twenty-seven patients underwent 61 GI endoscopies: 34 esophagogastroduodenoscopies, 17 colonoscopies, 7 flexible sigmoidoscopies, and 3 ileoscopies. Indications for endoscopy, which were not mutually exclusive, included chronic diarrhea (39%, n = 24), GI bleeding (36%, n = 22), suspected bacterial overgrowth (36%, n = 22), and suspected peptic disease (15%, n = 9). Based on gross endoscopic appearance, histopathology, or microbiology, 43 (70%) procedures yielded abnormalities. These included infectious (20%, n = 12), anatomical (18%, n = 11), peptic (15%, n = 9), allergic (15%, n = 9), and other (2%, n = 1) findings. Eleven (73%) of 15 duodenal cultures grew a spectrum of 17 bacterial species. Overall, 24 (89%) of 27 patients had gross endoscopic, histopathologic, or microbiologic abnormalities. CONCLUSIONS: In pediatric patients with IF, diagnostic upper and lower GI endoscopies yield high rates of abnormalities and can help guide clinical management.

Improved survival in a multidisciplinary short bowel syndrome program.

PURPOSE: Pediatric short bowel syndrome (SBS) remains a management challenge with significant mortality. In 1999, we initiated a multidisciplinary pediatric intestinal rehabilitation program. The purpose of this study was to determine if the multidisciplinary approach was associated with improved survival in this patient population. METHODS: The Center for Advanced Intestinal Rehabilitation includes dedicated staff in surgery, gastroenterology, nutrition, pharmacy, nursing, and social work. We reviewed the medical records of all inpatients and outpatients with severe SBS treated from 1999 to 2006. These patients were compared to a historical control group of 30 consecutive patients with severe SBS who were treated between 1986 and 1998. RESULTS: Fifty-four patients with severe SBS managed by the multidisciplinary program were identified. Median follow-up was 403 days. The mean residual small intestinal length was 70 +/- 36 vs 83 +/- 67 cm in the historical controls (P = NS). Mean peak direct bilirubin was 8.1 +/- 7.9 vs 9.0 +/- 7.4 mg/dL in controls (P = NS). Full enteral nutrition was achieved in 36 (67%) of 54 patients with severe SBS vs 20 (67%) of 30 patients in the control group (P = NS). The overall survival rate, however, was 89% (48/54), which is significantly higher than in the historical controls (70%, 21/30; P < .05). CONCLUSIONS: A multidisciplinary approach to intestinal rehabilitation allows for fully integrated care of inpatients and outpatients with SBS by fostering coordination of surgical, medical, and nutritional management. Our experience with 2 comparable cohorts demonstrates that this multidisciplinary approach is associated with improved survival.

Pediatric intestinal failure: nutrition, pharmacologic, and surgical approaches.

Intestinal failure (IF) is a condition where there is insufficient functional bowel to allow for adequate nutrient and fluid absorption to sustain adequate growth in children. Several etiologies can predispose to IF, including necrotizing enterocolitis, gastroschisis, and intestinal atresias. Intestinal rehabilitation can be seen as a 3-pronged strategy merging nutrition, pharmacologic, and surgical approaches to achieve the ultimate goal of enteral nutrition. Nutrition approaches should seek to facilitate transition from parenteral nutrition (PN) to enteral nutrition because prolonged use of PN is associated with severe morbidity and mortality. Enteral nutrition, on the other hand, promotes and enhances an adaptive response in the intestine. Medications used in the treatment of IF may help alleviate symptoms of diarrhea, bacterial overgrowth, and gastrointestinal dysmotility. Surgical procedures, such as longitudinal intestinal lengthening and tapering (LILT) or serial transverse enteroplasty (STEP), can increase mucosal surface area and may enhance intestinal adaptation. IF is a difficult disease process with a complex patient population and is best guided through this 3-pronged approach by a multidisciplinary team featuring surgeons, gastroenterologists, dietitians, pharmacists, and nurses.