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Purpose of Review: With the inherent therapeutic limitations of gut transplantation, the concept of surgical gut rehabilitation was introduced to restore nutritional autonomy in pediatric patients. With favorable outcomes in these young patients, there has been increasing interest in the applicability of gut rehabilitative surgery to a growing population of adults with gut failure due to various etiologies. We aim to review the current status of surgical gut rehabilitation for adult gut failure patients in the era of multidisciplinary gut rehabilitation and transplantation., Recent Findings: Indications for surgical gut rehabilitation have been gradually expanding, with gut failure after bariatric surgery recently added. Serial transverse enteroplasty (STEP) has been used with favorable outcomes in adult patients, including those with intrinsic intestinal disease. Autologous gut reconstruction (AGR) is the most frequently used surgical rehabilitative method; its outcome is further improved with conjunctive use of bowel lengthening and enterocyte growth factor as a part of comprehensive gut rehabilitation., Summary: Accumulated experiences have validated the efficacy of gut rehabilitation for survival, nutritional autonomy, and quality of life in adults with gut failure of various etiology. Further progress is expected with growing experience around the world., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose of Review: The intestinal rehabilitation program (IRP) is a comprehensive treatment strategy that employs various approaches implemented by multidisciplinary teams to treat intestinal failure in children. This program has shown promising results, such as reducing complications and improving prognosis and quality of life (QOL). In this review, we discuss the current status of this program and relevant topics., Recent Findings: IRP includes the prevention and treatment of various complications such as intestinal failure associated liver disease, catheter-related bloodstream infection or sepsis, and venous thromboembolism. In addition, treatment strategies such as glucagon-like peptide-2 analogs, surgical interventions, and intestinal transplantation have evolved over time and have contributed to improved outcomes. In addition, the scope and regions for IRP activities have expanded., Summary: IRP improves the prognosis and QOL of children with intestinal failure. The development of new drugs, surgical methods, and treatment strategies is expected to improve the current and future status of pediatric patients with intestinal failure. Furthermore, international institutions must collaborate, share knowledge, conduct joint research, and establish patient registries to advance IRP progress., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose of Review: Intestinal failure (IF) evolved from being the last recognized organ failure, to become one of the most progressive fields in terms of therapeutic alternatives and results. Short bowel syndrome (SBS) is the main cause of IF in adults and children. The use of surgery allowed patients with unfavorable anatomy type and length to be wean off parenteral nutrition. We aim to evaluate its current impact on intestinal rehabilitation., Recent Findings: Autologous gastro-intestinal reconstructive surgery (AGIRS), including bowel lengthening contributes by converting patient's anatomy to a more favorable one, improving quality of life, and modifying the natural history of the disease, allowing to recover intestinal autonomy in approximately 70% of the adults and 50% of the children's with SBS-IF. The current use of postsurgical medical rehabilitation strategies including the use of enterohormones complement the path to sufficiency, increasing the chances of success in both age group of patients., Summary: The development of AGIRS has changed the outcome of SBS-IF patients, becoming the main surgical procedure prescribed in multidisciplinary units, allowing to enhance the number of patients achieving intestinal autonomy throughout rehabilitation, leaving transplantation as the last surgical alternative., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose of Review: Intestinal failure secondary to short bowel syndrome is still a very serious condition. Treatment consists of parenteral nutrition to provide nutrients and maintain body weight. During the last decades, intestinal lengthening procedures have become more available. The goal of this review is to discuss the results of the literature on the most commonly performed intestinal lengthening procedures., Recent Findings: Longitudinal Intestinal Lengthening, Serial Transverse Enteroplasty (STEP), and Spiral Intestinal Lengthening and Tailoring (SILT) are currently the most frequently reported intestinal lengthening procedures. The most recent literature of these procedures is described with respect to indication, technical details, complications, short and long-term outcome, and PN independence., Summary: On the basis of indication, surgical complexity, complications, and clinical success, we conclude that the STEP procedure is probably the best choice for most centers., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose of Review: This article discusses the current state of the art in artificial intestine generation in the treatment of short bowel syndrome., Recent Findings: Short bowel syndrome defines the condition in which patients lack sufficient intestinal length to allow for adequate absorption of nutrition and fluids, and thus need parenteral support. Advances toward the development of an artificial intestine have improved dramatically since the first attempts in the 1980s, and the last decade has seen significant advances in understanding the intestinal stem cell niche, the growth of complex primary intestinal stem cells in culture, and fabrication of the biomaterials that can support the growth and differentiation of these stem cells. There has also been recent progress in understanding the role of the microbiota and the immune cells on the growth of intestinal cultures on scaffolds in animal models. Despite recent progress, there is much work to be done before the development of a functional artificial intestine for short bowel syndrome is successfully achieved., Summary: Continued concerted efforts by cell biologists, bioengineers, and clinician-scientists will be required for the development of an artificial intestine as a clinical treatment modality for short bowel syndrome.

Purpose of Review: Parenteral nutrition enables long-term survival in patients with intestinal failure; however, it is associated with life-threatening complications necessitating alternative techniques of management to enable weaning parenteral nutrition and minimizing parenteral nutrition-associated comorbidities. This review aims at discussing the indications and techniques most commonly utilized for surgical management in a short gut., Recent Findings: Surgical therapy for short gut has evolved and undergone refinement in the past 30-40  years with the older procedures being largely abandoned and replaced by newer and refined techniques. Lengthening surgeries (longitudinal intestinal lengthening and tapering and serial transverse enteroplasty) are the most commonly applied procedures in a dilated bowel with intestinal transplantation option reserved as a last resort for recurrent life-threatening central venous line infections, progressive loss of central venous access, and development of progressive liver disease., Summary: Management of intestinal failure requires a multidisciplinary approach to optimize intestinal rehabilitation and overall patient outcome. Although intestinal transplantation remains an excellent option for patients with severe life-threatening complications, autologous intestinal reconstruction appears to remain the better overall option.

Purpose of Review: The surgical management of short bowel syndrome now includes intestinal (ITx) and multivisceral transplantation (MVTx), which has advanced and is now a sustainable option for the treatment of intestinal failure. Improvements in immunosuppressive therapies, excellence in surgical and medical management and enhanced post-transplant monitoring have all contributed to optimizing this solid organ transplant as a means of supplanting the diseased native bowel and alimentary tract with a functional alternative., Recent Findings: Post-transplant management is a critical and challenging phase of gastrointestinal transplantation, and the transplant pathologist is an essential member of the transplant team who identifies many of the early and late complications after ITx and MVTx. Among the most injurious and common complications of ITx and MVTx is acute rejection and, to a lesser degree, chronic rejection. Both of these broad categories of rejection are principally identified by histopathological changes in the allograft; however, biomarkers and other laboratory analytes are rapidly evolving into critical ancillary tools in identifying and further characterizing the rejection process. Thus, the transplant pathologist must also be able to utilize numerous other laboratory tests and panels of molecular biomarkers that provide supplementary information to accompany the biopsy interpretation and clinical suspicion of rejection., Summary: Using biopsies and an assortment of additional approaches, the transplant pathologist is now able to provide swift and detailed information regarding the rejection process in the gastrointestinal transplant. This enables the clinical team to properly and successfully intercede, contributing to enhanced patient and graft survival.

Purpose of Review: Autologous intestinal reconstructive surgery has evolved over the past 3 decades from rescue to main surgical procedure in the multidisciplinary approach to short bowel syndrome (SBS) patients with intestinal failure. The purpose of this review is to clarify the actual place of intestinal reconstructive surgical techniques in the management of intestinal failure related to SBS and their relationship with intestinal transplantation., Recent Findings: Recent reports from centers of excellence in intestinal rehabilitation underline the efficacy and safety of autologous intestinal reconstructive surgery in patients with SBS. Outcome parameters as survival, parenteral nutrition weaning, and clinical conditions were improved in SBS patients treated by gastrointestinal reconstructive surgery., Summary: Autologous intestinal reconstructive procedures are pivotal to achieve enteral autonomy in patients with intestinal failure related to SBS. They should be considered mutually supportive and not antagonistic to intestinal transplantation.

Purpose of Review: Intestinal transplantation (ITx) and multivisceral transplantation (MVTx) has evolved into a viable treatment option for short bowel syndrome and intestinal failure due to a variety of factors including improved immunosuppressive regimens, superior surgical and medical management, and enhanced posttransplant monitoring., Recent Findings: The transplant pathologist is a central member of the transplant team in all phases of solid organ transplantation and as such, plays an important role in the evaluation of early and late complications after ITx and MVTx. Central among the tools for the pathologist is the mucosal biopsy, used for discerning histopathological changes in the allograft. The principal complications seen in the late posttransplant phase are acute rejection, chronic rejection, infections, and a variety of other inflammatory conditions. In order to more precisely characterize these conditions, the transplant pathologist must also be able to utilize numerous other laboratory tests and panels of molecular biomarkers that serve as ancillary information to complement the biopsy impression., Summary: Using this array of tools, the transplant pathologist is now able to provide rapid and precise information regarding the gastrointestinal (GI) transplant complications, a function that allows the clinical team to appropriately and successfully intervene and that helps contribute to the observed improvement in patient and graft survival.

Purpose of Review: Medical management of children with intestinal failure has gained increased relevance in recent years, in part owing to the growth of small bowel transplantation as a therapeutic option. The capacity of a patient to attain enteral autonomy through intestinal adaptation is critical in the decision process of whether or not transplantation is beneficial. This article reviews several important advances in the field of intestinal rehabilitation, focusing on enhancing adaptation and briefly mentioning recent insights into the morbidity of intestinal failure., Recent Findings: The field of intestinal rehabilitation has developed into a multidisciplinary venture with many facets. From a medical standpoint, intestinal adaptation efforts have come to focus upon identifying objective prognostic factors and therapies geared to increase functional gut mass. However, the stalwart of adaptive therapy remains the provision of enteral feeds, which must be balanced with nutritional goals. Although the common complications of parenteral nutrition therapy continue to affect outcomes, new therapies offer promise with regard to prevention of morbidity in this population., Summary: Medical intestinal rehabilitative therapy has progressed from the solitary concept of providing sufficient calories for growth to the promotion of enteral autonomy via intestinal adaptation. As strategies evolve with enhancing adaptation and minimizing morbidity, a clearer perspective will be gained regarding the difficult choice of rehabilitation versus transplantation as optimal therapy.

Purpose of Review: Multidisciplinary management of intestinal failure has progressed over the past 30 years, facilitating the transition to enteral autonomy in many pediatric patients. However, there remains a select group of patients who reach a plateau in advancement of their enteral nutrition. Numerous surgical options have been pursued to attempt to slow intestinal transit, taper dilated bowel, and promote intestinal adaptation. This review highlights the current literature on autologous intestinal reconstruction surgery, focusing on the two most commonly performed procedures, the longitudinal intestinal lengthening and tailoring (LILT) and serial transverse enteroplasty (STEP)., Recent Findings: LILT and STEP remain viable options to treat medically refractory short bowel syndrome. There is over 20 years of experience with the LILT procedure in the literature, with one large series showing that 67% of patients eventually transitioned to full enteral nutrition. The International STEP Data Registry reported a weaning rate of 34% after median follow-up of 12.6 months. Repeat STEP has been described as a possible treatment for the redilation that occurs after both LILT and STEP., Summary: LILT and STEP may facilitate enteral feeding advancement in patients with medically refractory short bowel syndrome.

Purpose of Review: To analyze the current status of living donor intestinal transplantation (LDIT) as a treatment option for intestinal failure., Recent Findings: Long-term outcomes from LDIT and combined living donor intestinal/liver transplantation (CLDILT) are comparable with those from transplantation using deceased donors. In certain life-threatening situations, especially in pediatric patients, this strategy may offer potential advantages., Summary: According United Network for Organ Sharing (UNOS) data children with intestinal failure affected by liver disease secondary to parenteral nutrition have the highest mortality on a waiting list compared with all candidates for solid organ transplantation. Elective nature of CLDILT offers multiple advantages for this patient population. LDIT also could be life-saving option for patients with intestinal failure who run out of venous access. Optimal timing, short ischemia time and good human leukocyte antigen (HLA) matching may contribute to lower postoperative complications. Current literature suggests that living intestinal donors experience very low morbidity and high level of satisfaction.

Purpose of Review: Immune monitoring is needed in small bowel transplantation (SBTx) because of a high incidence of rejection and graft loss, and life-threatening complications of high-dose prophylactic immunosuppression., Recent Findings: Clinical tests relevant to SBTx include methods to detect antidonor human leukocyte antigen antibodies, among which those which use known purified human leukocyte antigen peptides as substrates correlate best with graft loss; enumerate peripheral lymphocyte subsets to determine the efficacy of lymphocyte-depleting antibodies; estimate general immune function based on ATP production by mitogen-stimulated T-helper cells. Research tests that show clinical utility in SBTx recipients include following markers. First, flow cytometric mixed leukocyte responses, which detect donor-induced proliferation of recipient T-cytotoxic cells by dilution of the intravital dye carboxyfluorescein succinimidyl ester, or donor-induced CD154 expression in recipient T-cytotoxic memory cells. Among such tests, CD154 T-cytotoxic memory cells achieve the highest known sensitivity and specificity of at least 90% for the detection of acute cellular rejection. Second, elevated fecal calprotectin, an early screening marker for intestinal inflammation, which can indicate the need for a SBTx biopsy, especially after ileostomy stoma closure. Third, single-nucleotide polymorphisms associated with inflammatory bowel diseases, for example, nucleotide-binding oligomerization protein, macrophage stimulating 1, and so on. These single-nucleotide polymorphisms may be used to select the rejection-prone SBTx recipient for more potent immunosuppression, if additional studies confirm their associations with outcomes., Summary: The final approach to monitor the SBTx recipient will likely involve using the method(s) with the best sensitivity and specificity for detecting acute cellular rejection or graft loss during time periods when such events are most likely.

Purpose of Review: Intestinal transplantation is a treatment for patients with short bowel syndrome and associated severe complications. The intestine has long been seen as a 'forbidden' organ to transplant. This fact is because the first attempts at intestinal transplantation were rapidly defeated by rejection and sepsis., Recent Findings: Several factors have contributed to improve the results: tacrolimus-based immunosuppression, induction therapy (independent of the type), introduction of ganciclovir and rituximab and subsequent better control of cytomegalovirus and posttransplant lymphoma, better differential diagnosis between rejection versus infection and ischemia (avoiding unnecessary overimmunosuppression), better patient follow-up. Center experience is more important than a particular immunosuppressive protocol. M-TOR inhibitors, infliximab have been used. Mycophenolate mofetil is less frequently used because of its potential gastrointestinal toxicity. Of note, no significant improvement in short-term and long-term (>1 year) survival was observed since 2000 and 1985, respectively., Summary: Intestinal transplantation remains a formidable clinical/immunological challenge. With newer immunosuppression and accumulated experience, intestinal transplantation results have improved and the procedure represents a life-saving option in patients with short bowel syndrome-related complications. Before intestinal transplantation becomes a 'quality of life-improving' procedure (offered to patients who are free of short bowel syndrome-related complications), new strategies focusing on facilitating graft acceptance and reducing the need for immunosuppression will have to be developed.

Purpose of Review: Although intestinal transplantation is uniquely suited for the treatment of patients with intestinal failure suffering from life-threatening complications, patient survival at 5 years remains suboptimal at approximately 50-60%., Recent Findings: The introduction of effective medications to improve intestinal absorption, alternate intravenous lipid preparations that may reduce cholestasis and a technically easier nontransplant intestinal lengthening procedure have largely changed the available options for nontransplant interventions. Multidisciplinary teams created to manage the complexities of this population have shown improved outcomes and the ability to prevent or slow progression of life-threatening complications that would otherwise lead to intestinal transplantation in a large number of patients with short bowel syndrome., Summary: Here, we review the historical options, recent advances and cutting-edge research that will likely provide the basis for further advances in the treatment of patients with short bowel syndrome as the cause of their intestinal failure.