Absent ileocecal valve predicts the need for repeated step in children

Abstract

Background. Serial transverse enteroplasty facilitates weaning from parenteral support in selected patients with short bowel syndrome, although repeated procedure is frequently required. Our aim was to evaluate the outcome of a series of patients after serial transverse enteroplasty and define predictors of repeated serial transverse enteroplasty and weaning off parenteral support. Methods. All children who underwent serial transverse enteroplasty at 4 Nordic pediatric surgery centers from 2004-2015 were included in this observational study. Data were collected from the patient records. The study was approved by the local ethics review boards. Results. Twenty-seven children with short bowel with initial median small bowel length of 26 cm (range, 10-100 cm) were included. Eleven patients had the ileocecal valve remaining. Serial transverse enteroplasty was performed at median age of 7.5 months (range, 0.9-224 months). Serial transverse enteroplasty made the small bowel 46% (0-233%) longer. Eleven patients (41%) underwent a repeated serial transverse enteroplasty 12 months (1.0-72 months) later; 7 patients required additional operative procedures, but none were transplanted. At follow-up, 45.1 months (1.8-126 months) after the first serial transverse enteroplasty, 11 (41%) patients needed parenteral support. The remaining 16 patients had been weaned off parenteral support. One patient had died. Absence of the ileocecal valve was the only factor, which predicted the need for a repeated serial transverse enteroplasty (odds ratio 16.7, 95% confidence interval, 1.7-164.8, P = .007). No factor was identified predicting need for parenteral support at follow-up. Conclusion. A majority of children with short bowel syndrome can be weaned from parenteral support after serial transverse enteroplasty. The absence of the ileocecal valve predicts the need for a repeated serial transverse enteroplasty, which was required by 40% of the patients. (Surgery 2017;161:818-22.)

Short bowel mucosal morphology, proliferation and inflammation at first and repeat STEP procedures

“…Following first STEP between 30% and 88% of patients are weaned off PN 9 . Outcomes after repeat STEP procedures are often worse, reported weaning off rates ranging between 0% and 55% 10,13,14,20 . Though most patients in this study were not able to wean off PN after initial STEP procedure providing 42% increase in small bowel length, enteral energy tolerance had increased from 6% to 36% by the time of repeat STEP.…”

“…These findings are important, as intestinal mucosal inflammation and the lack of the ileocecal valve appears to have a central role in the pathophysiology of adaptation-associated small bowel dilatation and intestinal failure associated liver disease 4,23,24 . Recent clinical studies suggest that absent ileocecal valve predicts the need for repeat STEP 13 , while excessive adaptive small bowel dilatation is associated with intestinal inflammation, as measured by increased fecal calprotectin, and with bowel-derived blood stream infections, which seem to be instrumental in promoting hepatic inflammation and cholestasis 4,23,25 . Excessive small bowel dilatation hampers propulsive intestinal motility, which may in turn predispose to unfavorable changes in intestinal microbiota, inflammation and increased epithelial permeability 4,5,[26][27][28] .…”

“…Unfortunately, 40%-80% of the patients require repeat surgery mainly due to small intestinal redilatation after initial STEP, representing the major functional drawback of this operation [10][11][12][13][14] . The need for repeat STEP has been associated with absence of the ileocecal valve 13 , suggesting that this anatomic region may regulate intestinal growth, motility and its loss promotes microbiota which allow recurrence of dilatation and adversely affects STEP outcomes. However, underlying reasons for unsuccessful STEP remain unclear, while no data on intestinal histology in these patients are available.…”

“…samples. Notably, patients without an ileocecal valve showed over two-fold higher intraepithelial leukocyte count [14 IEL/100 enterocytes(11)(12)(13)(14)(15)(16)(17)] compared to patients with preserved ileocecal valve [6.4 (3.1-6.4), P=0.023)]…”

Intensive care and the surgical treatment children with the short bowel syndrome (review)

“…За даними T. Wester та співавт. (2017), відсутність баугінієвої заслінки визначає необхідність неодноразових операцій для видовження кишки [98].…”