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Infection due to multidrug-resistant Klebsiella pneumoniae is a common cause of graft resection after small bowel transplantation. We report a failed case in which the intestinal graft was resected 18 days after the operation due to postoperative infection with multidrug-resistant K pneumoniae and a literature review of other common causes of small bowel transplantation failure have been reported. A female, 29 years of age, underwent partial living small bowel transplantation for short bowel syndrome. After the operation, the patient was infected with multidrug-resistant K pneumoniae, even though various anti-infective regimens were employed. It further developed into sepsis and disseminated into intravascular coagulation, leading to exfoliation and necrosis of the intestinal mucosa. Finally, the intestinal graft had to be resected to save the patient's life. Multidrug-resistant K pneumoniae infection often affects the biological function of intestinal grafts and can even lead to necrosis. Other common causes of failure, including postoperative infection, rejection, post-transplantation lymphoproliferative disorder, graft-vs-host disease, surgical complications, and other related diseases, were also discussed throughout the literature review. Pathogenesis due to diverse and interrelated factors makes the survival of intestinal allografts a great challenge. Therefore, only by fully understanding and mastering the common causes of surgical failure can the success rate of small bowel transplantation be effectively improved. [ABSTRACT FROM AUTHOR]

Tolerance is the Holy Grail of solid organ transplantation (SOT) and remains its primary challenge since its inception. In this topic, the seminal contributions of Thomas Starzl at Pittsburgh University outlined foundational principles of graft acceptance and tolerance, with chimerism emerging as a pivotal factor. Immunologically, intestinal transplantation (ITx) poses a unique hurdle due to the inherent characteristics and functions of the small bowel, resulting in increased immunogenicity. This necessitates heavy immunosuppression (IS) while IS drugs side effects cause significant morbidity. In addition, current IS therapies fall short of inducing clinical tolerance and their discontinuation has been proven unattainable in most cases. This underscores the unfulfilled need for immunological modulation to safely reduce IS-related burdens. To address this challenge, the Leuven Immunomodulatory Protocol (LIP), introduced in 2000, incorporates various pro-tolerogenic interventions in both the donor to the recipient, with the aim of facilitating graft acceptance and improving outcome. This review seeks to provide an overview of the current understanding of tolerance in ITx and outline recent advances in this domain. [ABSTRACT FROM AUTHOR]

Short bowel syndrome (SBS) features nutrients malabsorption and impaired intestinal barrier. Patients with SBS are prone to sepsis, intestinal flora dysbiosis and intestinal failure associated liver disease. Protecting intestinal barrier and preventing complications are potential strategies for SBS treatment. This study aims to investigate the effects of farnesoid X receptor (FXR) agonist, obeticholic acid (OCA), have on intestinal barrier and ecological environment in SBS. Through testing the small intestine and serum samples of patients with SBS, impaired intestinal barrier was verified, as evidenced by reduced expressions of intestinal tight junction proteins (TJPs), increased levels of apoptosis and epithelial cell damage. The intestinal expressions of FXR and related downstream molecules were decreased in SBS patients. Then, global FXR activator OCA was used to further dissect the potential role of the FXR in a rat model of SBS. Low expressions of FXR-related molecules were observed on the small intestine of SBS rats, along with increased proinflammatory factors and damaged barrier function. Furthermore, SBS rats possessed significantly decreased body weight and elevated death rate. Supplementation with OCA mitigated the damaged intestinal barrier and increased proinflammatory factors in SBS rats, accompanied by activated FXR-related molecules. Using 16S rDNA sequencing, the regulatory role of OCA on gut microbiota in SBS rats was witnessed. LPS stimulation to Caco-2 cells induced apoptosis and overexpression of proinflammatory factors in vitro. OCA incubation of LPS-pretreated Caco-2 cells activated FXR-related molecules, increased the expressions of TJPs, ameliorated apoptosis and inhibited overexpression of proinflammatory factors. OCA supplementation could effectively ameliorate the intestinal barrier disruption and inhibit overexpression of proinflammatory factors in a rat model of SBS and LPS-pretreated Caco-2 cells. As a selective activator of FXR, OCA might realize its protective function through FXR activation. The FXR agonist, OCA, attenuates the intestinal barrier disruption in a rat model of short bowel syndrome. [Display omitted] • OCA upregulates the repressed FXR expression in SBS rats and Caco-2 cells. • OCA ameliorates the intestinal barrier disruption in SBS rats and LPS-pretreated Caco-2 cells. • OCA, as a selective activator of FXR, might realize its protective function through FXR activation. • Targeting FXR might offer new promises in SBS-induced intestinal barrier disruption. [ABSTRACT FROM AUTHOR]

Purpose: Creation of an optimal bowel anastomosis with low postoperative leakage rate is an immanent part of colorectal surgery contributing to recovery, length of hospital stay and overall hospital costs. We aimed to investigate costs of small and large bowel resection, length of hospital stay, anastomotic leakage rate and its risk factors depending on the anastomotic technique.Methods: Retrospective analysis of 198 patients (67 stapled and 131 hand-sewn anastomoses) undergoing elective bowel resection with a single anastomosis without protective ileostomy either stapled or in double-rowed running suture technique between 1st October 2012 and 30th September 2018 at Charité University Hospital Berlin, Campus Benjamin Franklin. We analyzed costs of treatment, total length of hospital stay, rate of anastomotic leakage and possible risk factors for anastomotic leak.Results: No significant difference between both anastomotic techniques could be detected for hospital stay (p = 0.754), 30-day-readmission rate (p = 0.827), or anastomotic leakage (p = 606). Neither comorbidities (p = 0.449), underlying disease (p = 0.132), experience of the surgical team (p = 0.828) nor scheduling of the operation (p = 0.531) were associated with anastomotic leakage. Stapled anastomoses took 22 min less operation time than sutured anastomoses (130 vs. 152 min. Median) (p = 0.001). Operations with stapled anastomoses saved 183 € in operation costs and 496 € in overall hospital costs.Conclusion: Stapled and hand-sewn bowel anastomoses can be performed equally safe without differences in postoperative outcome. No patient, procedure or surgeon related risk factors for anastomotic leakage could be detected. Bowel resections with stapled anastomoses take less time and save operation and overall hospital costs. [ABSTRACT FROM AUTHOR]

Inflammatory bowel disease, vascular disease, volvulus, adhesions, or abdominal trauma may necessitate extensive small-bowel resection resulting in an ultra-short distal duodenal or jejunal stump. If this distal duodenal or short jejunal stump is too short for stoma creation and bowel continuity restoration is hazardous or not possible at all, a distal duodenogastrostomy or proximal jejunogastrostomy in combination with drainage of the stomach is an option to prevent stump leakage. Although successful, this distal duodenogastrostomy has been described only in very few patients and in older records. We reintroduced this technique and describe a recent series of patients that confirms its usefulness in certain conditions. The technique of the distal duodenogastrostomy or proximal jejunogastrostomy with gastric drainage was used for the management of the difficult distal duodenum stump in five critically ill patients undergoing extensive bowel resection. Four patients with small-bowel ischemia and one patient suffering from perforating Crohn's disease and small-bowel volvulus were treated  successfully. The gastrostomies were subsequently converted to a duodenotransversostomy (in two patients) or the patients underwent small-bowel transplantation (two patients). One patient still has a jejunogastrostomy just after the duodenal-jejunal transition. In all five patients, the distal duodenogastrostomy or proximal jejunogastrostomy in combination with gastric drainage functioned well up to restoration of bowel continuity. In one patient, distal duodenogastrostomy and transabdominal gastric drainage functioned well for 5 years. No anastomotic leakage occurred. This procedure provides a feasible solution for an ultra-short bowel at emergency laparotomy. It enhances the surgical armamentarium and provides treatment options for these patients that were perhaps previously deemed unsalvageable. [ABSTRACT FROM AUTHOR]

Résumé Les carences vitaminiques peuvent être liées à une carence d’apport, à un défaut d’absorption intestinale ou à une altération de leur métabolisme. La majorité des transporteurs permettant l’absorption des vitamines par les entérocytes a été identifiée au cours des vingt dernières années. L’objectif de cette revue est de présenter une mise au point actualisée afin d’aider le clinicien à identifier les situations cliniques à risque de carences en vitamines hydrosolubles et liposolubles du fait d’un défaut d’absorption intestinale. La première partie de cette revue précise les sites ainsi que les transporteurs impliqués dans l’absorption intestinale des vitamines. La seconde partie rapporte les principaux facteurs (médicaments, pathologies gastro-intestinales, consommation d’alcool) influençant l’absorption intestinale des vitamines. Certains médicaments ainsi que l’alcool peuvent inhiber l’absorption des vitamines hydrosolubles du fait d’une compétition au niveau des transporteurs entérocytaires. L’absorption des vitamines liposolubles est pour sa part directement liée à l’absorption des lipides. Elle est donc diminuée dans les pathologies gastro-intestinales induisant une stéatorrhée. Une partie des connaissances dans le champ de l’absorption intestinale des vitamines provient d’études in vitro. La pertinence de ces études en pratique clinique reste, dans un certain nombre de cas, à démontrer suggérant des pistes de recherches pour l’avenir. Poor vitamin intake, diminished intestinal absorption or metabolism alteration can all contribute to vitamin deficiencies. Over the last twenty years, advances in molecular biology have helped to identify the majority of intestinal vitamin transporters. The purpose of this review was to summarise the state of the art in this field to help the clinicians to recognise potential clinical risk situations related to alteration of vitamin absorption. Firstly, this review detailed the intestinal absorption site and the related transporter for each vitamin. Secondly, it reported the main factors able to alter vitamin absorption. Actually, different factors, such as drugs, alcohol or intestinal resection and gastrointestinal disorders modulate vitamin absorption. Water-soluble vitamins are mainly impacted by a competitive mechanism for their transport. Fat-soluble vitamin absorption is highly dependent on the lipid absorption, and, thus, gastrointestinal disorders inducing steatorrhea are at risk of fat-soluble vitamin deficiencies. Some of the knowledge in this field was provided by in vitro studies. Future studies on the current topic are required to transpose these studies in clinical practice. We highlighted gaps in the vitamin absorption field to suggest future research directions. [ABSTRACT FROM AUTHOR]

Congenital Short Bowel Syndrome (CSBS) is a rare gastrointestinal disorder in which the mean length of the small intestine is substantially reduced when compared to its normal counterpart. Families with several affected members have been described and CSBS has been suggested to have a genetic basis. Recently, our group found mutations in CLMP as the cause of the recessive form of CSBS, and mutations in FLNA as the cause of the X-linked form of the disease. These findings have improved the quality of genetic counselling for CSBS patients and made prenatal diagnostics possible. Moreover, they provided a reliable starting point to further investigate the pathogenesis of CSBS, and to better understand the development of the small intestine. In this review, we present our current knowledge on CSBS and discuss hypotheses on how the recent genetic findings can help understand the cause of CSBS. [ABSTRACT FROM AUTHOR]

Résumé: L’interruption de l’intestin grêle par une entérostomie double peut entraîner un syndrome de grêle court de type 1 responsable d’une insuffisance intestinale sévère qui nécessite des apports parentéraux pour couvrir les besoins et compenser les pertes. La réinstillation du chyme est une technique qui rétablit la continuité fonctionnelle de l’intestin anatomiquement présent grâce à une circulation extracorporelle du chyme. Recueilli à sa sortie de la stomie afférente, le chyme est réinjecté immédiatement dans l’intestin efférent hors circuit, sans manipulation, grâce à une pompe spécifique. Les patients se nourrissent alors de ce qu’ils mangent, n’ont plus de pertes hydro-électrolytiques et les apports parentéraux sont arrêtés en quelques jours. La réinstillation du chyme est réalisable à domicile avec des pompes portables spécifiques, chez des patients volontaires qui reçoivent une éducation thérapeutique particulière, en attendant le rétablissement chirurgical de la continuité intestinale. [ABSTRACT FROM AUTHOR]

Abstract: Background and aim: Citrulline is a non-protein amino acid synthesized in the small intestine. In children with short-bowel syndrome, citrulline has served as a reliable marker of the residual bowel length and parenteral nutrition (PN) independence. In the present study we aim to assess the value of citrulline measurement in preterm neonates developing necrotizing enterocolitis (NEC). Methods: Plasma citrulline levels were measured prospectively in 17 preterm neonates with NEC stage II during the entire course of the disease. Serial citrulline determinations in 24 healthy preterm neonates on 2, 7, 14, 21 and 28days of life (DOL), served as reference values. Results: In healthy preterm neonates plasma citrulline levels showed a progressive increase in relation to age. In neonates presenting with NEC, mean citrulline levels were significantly lower as compared to controls'' citrulline levels of the most approximate day of life (DOL 7: 16.85±4.2 vs 20.5±4.5μmol/L, p<0.05; DOL 14: 18±4.2 vs 23.5±4.3μmol/L, p<0.01; DOL 21: 17±2.5 vs 30±5.7μmol/L, p<0.01). The optimal citrulline cut-off distinguishing NEC patient from controls was 17.75μmol/L (sensitivity 76%, specificity 87%). Plasma citrulline at presentation correlated inversely with the duration of parenteral nutrition (r=−0.49, p<0.05). Consecutive citrulline determinations revealed that plasma citrulline increased during reintroduction and gradual increase of enteral nutrition. Conclusions: Our findings provide preliminary evidence that citrulline levels that are reduced in preterm neonates with NEC in comparison to age-matched controls and serial citrulline determinations could help to monitor improvement of functional enterocyte mass during the course and resolution of NEC. [Copyright &y& Elsevier]

Abstract: A five year old girl was admitted to the hospital for evaluation of intermittent ataxia. She had undergone serial resections of the small intestine after birth, resulting in short bowel syndrome. Lactomin was prescribed for watery diarrhea at twice the regular dose 2weeks before the onset of neurologic symptoms. D-lactic acidosis was diagnosed on the basis of a plasma D-lactate level of 5.537mmol/l. Lactomin was discontinued, and she was treated with sodium bicarbonate and oral antibiotics. The probiotics the patient had taken were likely the cause of D-lactic acidosis and should therefore be avoided in patients with short bowel syndrome. [ABSTRACT FROM AUTHOR]

Early postoperative complications after small bowel transplantation (SBT) are likely mediated, at least in part, by dysmotility caused by the obligate disruption of extrinsic and enteric nerves in the graft. Adrenergic hypersensitivity of gut smooth muscle has been observed in some (but not all) segments of intestine in various experimental models of SBT, highlighting regional and species variability in response to denervation. Little is known about changes in canine longitudinal muscle after extrinsic denervation. Six dogs each underwent either complete extrinsic denervation of the jejunoileum or a control operation (transection and reanastomosis of the proximal jejunum and distal ileum). In vitro contractile response of longitudinal muscle strips to norepinephrine was evaluated at the time of the operation, and 2 weeks and 8 weeks later. After extrinsic denervation, the jejunal response to norepinephrine was preserved at all time points; however, the ileum displayed a decreased sensitivity to norepinephrine, an effect unmasked after intramural neural blockade with tetrodotoxin. These data support a potential for neurally mediated dysmotility after SBT and reinforce the differences in responses to extrinsic denervation between species, as well as differences within different regions and between anatomic segments of small intestine in the same species. ( J Gastrointest Surg 2002;6:418–425.) [ABSTRACT FROM AUTHOR]

Segmental small bowel transplantation offers theoretic advantages over total jejunoileal transplantation, but the regional ability of the transplanted segment to adapt is unknown. Absorption was measured in an 80 cm jejunal segment via a triple-lumen perfusion technique. Separate experiments measuring absorption of four nutrients (glucose, glutamine, oleic acid, and taurocholic acid) were performed before and 2 and 12 weeks after operative intervention. Control dogs (CON, n = 6) underwent distal 50% enterectomy. Experimental dogs (EXT DEN, n = 6), in addition to resection, underwent complete extrinsic denervation of the remaining jejunum. All dogs developed diarrhea, which rhesolved in all CON dogs but persisted in all EXT DEN dogs. Maximal weight loss was greater in the EXT DEN group. Glucose and oleate absorption was decreased 2 weeks after ileal resection in both the CON and EXT DEN dogs; glutamine absorption was decreased at 2 weeks in EXT DEN dogs only. Taurocholate and water absorption remained unchanged in both groups. Absorption of all solutes returned to baseline at 12 weeks in both groups. Despite greater weight loss and persistent diarrhea in EXT DEN dogs, at 12 weeks there were no differences in net absorptive fluxes between the EXT DEN and the CON group after extrinsic denervation. The extrinsic denervation necessitated by small bowel transplantation does not appear to blunt the net jejunal adaptive response to total ileal resection, but may temporarily alter glutamine absorption. ( J Gastrointest Surg 2002;6:240–247.) [Copyright &y& Elsevier]

• Novel bioresorbable Zinc matrix nanocomposite springs are successfully fabricated. • These spring implants are for potential Short Bowel Syndrome treatment. • The hardness of Zn/Tungsten Carbide is significantly enhanced over pure zinc. • Young's modulus of Zn nanocomposites is tunable by different nanoparticle contents. • Tunable Young's modulus offers tunable spring constants. Short Bowel Syndrome (SBS) is a devastating disease that affects thousands of lives every year. Patients diagnosed with SBS have malabsorption. Recently, endoscopically inserted springs were used to lengthen the small intestines. However, the springs are not biodegradable and need to be surgically removed after lengthening. Zinc, as a novel biodegradable material with suitable corrosion rate, is promising for this application. unfortunately, zinc lacks the mechanical strength to be used as effective springs. In this study, we successfully designed and fabricated a biodegradable Zn-WC nanocomposite spring with enhanced and tunable mechanical strengths to meet with requirements of springs for in vivo animal testing. [ABSTRACT FROM AUTHOR]

Abstract: Short bowel syndrome is characterized as a state of malabsorption after massive resection of the small intestine. It has a wide spectrum of clinical presentations, from mild to severe depending predominantly on the length of intestine remnant. Management is challenging and requires vigorous attention to every detail. Enteral nutrition is the key to intestinal adaptation and reduction of dependency on parenteral nutrition. Therefore, creative ways are essential to maximize enteral nutrition despite obstacles to its use. [Copyright &y& Elsevier]

Displacement of the bladder outside of the pelvis by way of the inguinal canal represents an infrequent presentation of an inguinal hernia that rarely causes urinary tract obstruction. However, bladder hernias can become bothersome, painful, and potentially dangerous. We report a 56-year-old man with a chronic bladder hernia who became acutely unable to empty his bladder from its position in the right hemiscrotum after a motor vehicle accident. At hernia repair, bladder and ischemic bowel were discovered, mandating significant small bowel resection. This case presents interesting considerations and potential pitfalls when evaluating a patient with a bladder hernia. [Copyright &y& Elsevier]