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The term intestinal failure (IF) is understood as the transient or irreversible loss of the resorptive capacity of the bowels. This includes a multitude of diseases, some of which have anatomical causes and others functional causes. The functional capacity (absorption and motility) of the remaining digestive tract and the bacterial overgrowth and false colonization of the small bowel are of prognostic importance. After exclusion of pathological intestinal findings, such as stenosis and dilatation, initially conservative treatment is employed with the aim of intestinal adaptation. Before failure or complications, initially conservative surgery and then organ replacement by transplantation should be considered. The IF is a temporary or permanent condition. For adults a length of 100cm small bowel without the colon, 60cm still with continuity to the colon and 35cm small bowel with complete preservation of the colon including the ileocecal valve are potentially sufficient for intestinal autonomy.Unter dem Terminus Darmversagen, akut oder chronisch („intestinal failure“, IF), versteht man den transienten oder irreversiblen Ausfall der resorptiven Kapazität des Dünndarms. Hierzu gehört eine Vielzahl von Erkrankungen – einige haben anatomische, andere funktionelle Ursachen. Die funktionelle Kapazität (Absorption und Motilität) des verbleibenden Verdauungstrakts und die bakterielle Überwucherung und Fehlbesiedlung des Dünndarms sind von prognostischer Bedeutung. Zu Beginn steht nach Ausschluss pathologischer intestinaler Befunde, wie Stenosen und Dilatationen, die konservative Therapie mit dem Ziel der intestinalen Adaptation. Vor Versagen oder Komplikationen sollten zunächst konservative chirurgische, dann der Organersatz durch Transplantation erwogen werden. Das IF ist ein temporärer oder dauerhafter Zustand. Für Erwachsene gilt eine Länge von 100 cm gesundem Dünndarm ohne Kolon, 60 cm mit noch Kolon in Kontinuität und 35 cm Dünndarm bei komplettem Erhalt des Kolons inklusive der Ileozökalklappe als potenziell ausreichend für eine intestinale Autonomie.

Short-bowel-syndrome (SBS) is an often chronic disease with high morbidity. The aim of this study was to evaluate the complexity of SBS treatment and the economic burden on a treating hospital. Anonymized data of eleven consecutive SBS patients from the University Hospital of Bonn were included. Parameters of medical resources were considered for year of diagnosis (YOD) and a follow-up (FU) period of three years. Subsequently, costs were evaluated according to the corresponding catalogues. Median inpatient days were 96 days in YOD and decreased to three days in the third year of FU. Median cost of inpatient treatment decreased from approximately 84 500 € auf 3200 €. While major visceral surgery was usually required in the YOD, catheter-associated interventions dominated during further FU. Actual reimbursement according to the G-DRG covered approximately 50 % of inpatient treatment cost, for outpatient care only est. 16.5 % of costs were covered. Annual costs for medication, parenteral nutrition and GLP-2-analogon treatment added up to 6752 €, 48 485 € and 138 442 €, respectively. The interdisciplinary medical care of SBS-patients is resource-intensive and expensive. The required treatment shifts from the in- to the outpatient sector. Both settings are at present not adequately reimbursed. Hence, this imbalance may endanger adequate care for SBS-patients in the future in times of economic rationale. In concordance with other rare disease management programs, additional measures are needed to provide and improve interdisciplinary treatment of SBS. Das Kurzdarmsyndrom (KDS) ist eine oft chronische Erkrankung mit hoher Morbidität. Diese Untersuchung sollte Versorgungsrealität und -kosten bei der Behandlung von KDS aus Sicht eines Maximalversorgers mit angeschlossener Hochschulambulanz darstellen. Es wurden Behandlungsdaten von elf konsekutiven KDS-Patienten am Universitätsklinikum Bonn über vier Jahre anonymisiert ausgewertet. Die ermittelten Leistungen wurden für das Diagnosejahr und drei folgende Behandlungsjahre entsprechend geltenden Leistungskatalogen monetär bewertet. Die medianen stationären Tage reduzierten sich von 96 (Diagnosejahr) auf drei Tage im dritten Jahr. Dementsprechend sanken die medianen stationären Therapiekosten von rund 84 500 € auf 3200 €. Die operativen Maßnahmen verlagerten sich von komplexen viszeralchirurgischen Operationen zu meist gefäßchirurgischen Interventionen zur Aufrechterhaltung der venösen Zugangswege. Die DRG-Pauschalen deckten nur rund 50 % der tatsächlichen stationären Kosten. Die Hochschulambulanz-Pauschale deckte rund 16,5 % der ambulanten Leistung. Die jährlichen medianen Kosten für Arzneimittel betrugen 6752 €, für parenterale Ernährung 48 485 € und für die Therapie mit einem GLP-2-Analogon 138 442 €. Die interdisziplinäre Versorgung von KDS-Patienten ist kosten- und ressourcenintensiv. Sie verlagert sich vom stationären in den ambulanten Sektor. Weder die stationäre noch die ambulante Behandlung ist zurzeit kostendeckend vergütet. Dies führt zu fortbestehenden Mängeln der Patientenversorgung in Zeiten ökonomischer Rationalisierung, sodass von der Notwendigkeit zusätzlicher Maßnahmen analog zur sektorenübergreifenden Versorgungsverbesserung bei anderen seltenen Erkrankungen auszugehen ist.

Patients with severely orally decompensated malsaborption due to surgical rescetion suffer from short bowel syndrome (SBS). The resultant decrease in intestinal surface area after rescetion of parts of the intestines leads to chronic functional intestinal insufficiency or even complete failure (cIF) which requires parenteral fluid and nutrient restoration for establishment of metabolc stability. Since the introduction of glucagon-like peptide (GLP)-2 analogues such as teduglutide functional rehabilitation of the remaining gastrointestinal tract has become a causal treatment option. Teduglutide functionally and effectively enhances intestinal absorption of fluid as well micro- and macronutrients allowing a reduction of parenteral nutrition and/or volume with even complete weaning off in some patients. This results increased metabolic stability, oral autonomy, quality of life and putatively less complications.Das chronische Darmversagen (CVD) bei Kurzdarmsyndrom (KDS) wird sowohl durch die postoperative Anatomie als auch funktionell anhand des parenteralen Kalorien- und Volumenbedarfs klassifiziert.Die postoperative Anpassungsreaktion nach Darmresektion verläuft in 3 Phasen, die jeweils eines interdisziplinären Managements bedürfen.Ziel der Therapie ist eine ausreichende Kalorien- und Nährstoffversorgung unter Vermeidung einer Hyperalimentation bzw. die Linderung/Beherrschung der Diarrhöen. CHIRURGISCHE MAßNAHMEN EINSCHLIEßLICH TRANSPLANTATION: Die chirurgische Wiederherstellung der Kontinuität ausgeschalteter Darmabschnitte ist unverzichtbar. Es bestehen prinzipiell verschiedene Optionen der Transplantation, der Nachweis für eine Verbesserung der Gesamtprognose steht allerdings noch aus. FUNKTIONELLE INTESTINALE REHABILITATION DURCH GLP-2-ANALOGA: Durch die Einführung von Glucagon-like-peptide-2-Analoga (GLP-2-Analoga) in die funktionelle intestinale Rehabilitation von KDS-Patienten ist nunmehr eine kausale Behandlung dieses Malabsorptionssyndroms möglich. Durch die GLP-2-Analoga-vermittelte Steigerung der Flüssigkeits-, Nährstoff- und Kalorienabsorption ist eine Reduzierung der parenteralen Substitution (PS), im Idealfall mit kompletter Entwöhnung, möglich.

Intestinal failure is characterized by intestinal water and electrolyte losses as well as malabsorption of macronutrients. It often requires individually composed parenteral support (so call compounding). Teduglutide, a DPP-IV resistant GLP2 analogue, is available a pharmacologic treatment, which stimulates intestinal absorption and can facilitate infusion free days. Catheter infections are the most common complication of home parenteral support. The incidence can be minimized using Taurolidin as a catheter block solution.

Surgical treatment is primarily used to treat complications of Crohn's disease but also to improve the quality of life. An adequate preoperative preparation including improvement of the nutritional status, weaning off or stopping immunosuppressive medication and preoperative drainage of abscesses can decrease the complication rate. With the exception of when neoplasia is present, bowel-sparing techniques (e. g. strictureplasty and limited resection) are now standard, which has resulted in a low risk of short bowel syndrome. The laparoscopic approach is possible for most indications even in the case of recurrent disease, in primary ileocecal resection the laparoscopic approach has been shown to be superior to the open approach. None of the available techniques for anastomotic reconstruction of the bowels has been shown to be superior. A drainage seton is a good option to retain the quality of life in complex fistulas and reconstructive repair should only be considered when the rectum is free from inflammation.

Patients with ileostomies regularly suffer from short bowel syndrome or high volume output associated with loss of absorptive surface and subsequent impairment of absorption for drugs and different nutrients resulting in electrolyte and fluid balance disorders as well as renal insufficiency. Adaptation of these fundamental functions of the gut with adequate fluid uptake, absorption of sufficient different nutrients and vitamins represents a major challenge to rehabilitate these patients shortly after surgery. Patients with ileostomy often develop metabolic acidosis with normal anion gap. In our retrospective study we would like to draw attention to these metabolic disorders in patients with ileostomy in comparison to patients with colostomy and patients undergoing gastrectomy for gastric cancer.In the period from 2005 to 2012 we examined 164 patients with ileostomy in our rehabilitation clinic, 109 patients with colostomy and 193 patients after surgery for gastric cancer of the possible presence of metabolic acidosis by using capillary blood gas analysis (metabolic acidosis was anticipated, if base excess was ≤- 3,0 mmol/l). Patients are treated as inpatients both in early stage and for follow-up rehabilitation. The length of time in our rehabilitation clinic lies in between 24-28 days. On the basis of random samples we tested blood samples in 19 patients with ileostomy in succession for ferritin, folic acid, zinc, selenium and vitamin B12. Statistical analysis comprised the classical intervals (mean and standard deviation, range and T-test for dependent and independent samples).In total we tested 164 inpatients with ileostomy in our rehabilitation clinic (median age 67.4 years, range 19-79 years). Surgery for ileostomy took place about 1.4 months on average ago (range ¼-56 months). 60 (36.5%) inpatients suffered from metabolic acidosis often combined with renal insufficiency. Supportive therapy intravenously administered in 10 patients and sodium bicarbonate given by mouth in 40 patients significantly improved metabolic acid (base excess improved on average from -7.2 to -3.2 mmol/l, p0.00138) and renal function calculated on the basis of serum creatinine (serum creatinine decreased from 1.49 on average to 1.34 mg/dl, p0.04039). Body weight remained constant over the whole period on average with 74 kg. Diuretics did not show any influence on the base excess. In 19 patients with ileostomy who did not take any kind of supplements, among the parameters tested were a high percentage of zinc (9 of 19 patients, 47%) and selenium deficiency (13 of 19 patients, 68%). 50 patients with ileostomy were younger than 65 years of age and thus in the working age population. In the group of patients after gastrectomy because of gastric cancer (n=193, median age 69.1 years, range 36-82 years), surgery for gastrectomy took place about 1.8 months on average ago and in this group only 14 patients (7%) showed metabolic acidosis. In the group of patients with colostomy (n=109, median age 69.5 years, range 39-82 years), surgery for colostomy took place about 2.1 months on average ago and in this group only 6 patients (5.5%) suffered from metabolic acidosis.Medical rehabilitation is indicated for patients with enterostoma. Acceptance of the enterostoma by the patient himself, psychological stabilization, achievement of self-sufficiency in stoma care, improvement of physical abilities and finally being fit for full or limited employment are the most important objectives in rehabilitation medicine. Metabolic acidosis was often found in patients with ileostomy and was an important clinical appearance. Blood gas analysis is recommended to verify metabolic acidosis and if confirmed sodium bicarbonate and in cases of high volume output salt-depleting ileostomy additionally intravenous fluid support should be offered controlling body weight in the follow-up. As could be shown by our analysis patients with ileostomy should also be tested for zinc and selenium deficiency.

As data about prevalence and standard of care in short bowel syndrome (SBS) are not available for Germany, this study estimated the prevalence and assessed the medical infrastructure to potentially improve care of SBS patients.In a validated approach for prevalence estimation in rare diseases, a randomized census of 478 size-stratified hospitals with surgical, internal medicine and pediatric departments was conducted to estimate SBS prevalence. The number of SBS patients, specialized outpatient clinics and caregiver expertise were assessed.The response rate was 85 % of randomized hospitals (405/478). Strata-derived estimation yielded a total of 2,808 SBS patients in Germany for 2011/2012 (95 % CI: 1750.3865), translating into a prevalence estimation for 34/million inhabitants (95 % CI: 21.47). Overall expertise in SBS treatment was only rated "satisfactory" by most caregivers. While 86 specialized outpatient clinics were identified, there was no central registry to access these resources.Short bowel syndrome, with a newly estimated prevalence of 34/million inhabitants is not a very rare medical condition in Germany. The interdisciplinary approach needed for optimal care for SBS patients would be greatly facilitated by a central registry.

From a gastroenterological point of view, for chronic critically ill patients a differentiation has to be made between general gastroenterological problems, which are important in many or all chronic critically ill patients and patients with gastroenterological diseases which are the reason for the chronic critically ill status. General gastroenterological problems are, for example the nutrition of these patients and also considerations about ulcer prophylaxis or gastroenterological complications, such as antibiotic-associated colitis. Gastroenterological diseases as the reason for a chronic critically ill status are more in the minority. Diseases which should be taken into consideration are advanced liver cirrhosis and short bowel syndrome. This manuscript is intended to discuss gastroenterological problems in this selected group of patients and to show possible solutions and treatment options.

There are several reasons for the possible development of a short bowel syndrome, which, however, occurs only rarely. The main causes consist of extended intestinal resections in cases of congenital anomalies (e.g., gastroschisis, intestinal atresia or dysplasia) or ischaemic lesions due to a volvulus. In addition, an intestinal stoma at a more upper segment of the GI tract can result in the functional manifestation of a short bowel syndrome. The differentiation between temporary and persisting types is essential for initiation of an adequate treatment. Loss or exclusion of organic resorption area at the inner surface of the (small) intestine can be associated with numerous pathological consequences requiring treatment. As a principle consideration from the paediatric point of view, the potential of intestinal adaptation needs to be assessed. Basic conservative treatment options are parenteral and enteral nutrition regimens, in particular, to prevent complications (such as D-lactate acidosis). The main surgical approaches are the procedures called LILT (longitudinal intestinal lengthening and tailoring) according to Bianchi and STEP (serial transverse enteroplasty). The technique to create intestinal segments of antiperistalsis has been abandoned. Because of the encouraging results of intestinal transplantation, this novel treatment option has gained greater attention over the past few years and is now also an option for paediatric patients. The limiting factor and thus major complication is the central venous catheter for long-term treatment. Catheter-related complications are still the main reason for a considerable mortality in these children.

Short bowel syndrome (SBS) is defined in adults as a malabsorption disorder as a result of shortening the bowel to200 cm. The severity of symptoms is less dependent on the amount of residual intestine than on the anatomical position of the resected bowel, the type of operative reconstruction, and the type and quality of nutritional, medical, and surgical treatment. Numerous complications and deficiency symptoms are associated with SBS. The extent of deficient nutrition should be determined. The need to create accesses for enteral and parenteral delivery, to supply supplementation as needed, perform pharmacological therapy, and in individual cases surgical treatment all necessitate a broad knowledge of nutritional medicine. The goals of therapy are correction and prevention of malnourishment, restoration of a normal nutritional status, and the normal thriving of children. Complications should be avoided, particularly those problems associated with parenteral nutrition. The frequency of diarrhea should be reduced. Overall, the aim is to achieve an optimized quality of life.

Gastrointestinal surgery may not only lead to early postoperative complications but also chronic consequences. These have therapeutic implications for affected patients. The kind and extent of surgical intervention determines the spectrum of postsurgical phenomena which may occur. These chronic consequences are due to changes in gastrointestinal anatomy, the synchronization of digestive processes, or the ability to digest and absorb food. In case of transplantation surgery, adverse effects of immunosuppression have to be considered. Sometimes, chronic consequences of surgical procedures are difficult to recognize. The knowledge of typical problems associated with gastrointestinal surgery is necessary to enable early and timely diagnosis and treatment. Some negative effects can be avoided by early therapeutic interventions. This article summarizes typical chronic consequences of gastrointestinal surgery.

Diarrhoea, malabsorption and malnutrition characterise the short bowel syndrome. The underlying gastrointestinal disorders, the types of intestinal resections performed and the subsequent pathophysiological situations are reviewed. Recommended therapeutic measures in the postoperative period as well as in the rehabilitation of patients with short bowel syndrome are discussed in more detail. In the postoperative period, parenteral nutrition is essential followed by an enteral diet to stimulate bowel adaptation, reduce fluid loss and increase nutrient absorption. The final diet should be based on the anatomy of the retained bowel (presence or absence of a colon and ileum). The importance of the colon as a digestive organ in patients with short bowel and the need of a low-oxalate diet are underlined. The possible benefit of new treatment options (glutamine, growth hormone and glucagon-like peptide 2) is discussed. Both typical complications of the short bowel syndrome and management of these complications are presented.

Intestinal transplantation (ITx) is the only causal therapy of short bowel syndrome (SBS). Long-term survival after ITx has been improved significantly during the last years. The experience with ITx at the Charite, Campus Virchow Klinikum, are described and discussed.Twelve isolated ITx and one multivisceral transplantation (including stomach, pancreatodudenal complex, small intestine, liver, ascending colon, right kidney, and adrenal gland) were performed. Mean recipient age was 37.7+/-10.6 yrs (median: 35 yrs; range: 27 - 58 yrs; M:F = 8:5). All patients had irreversible SBS (0 - 30 cm residual bowel length; mean: 11.8+/-11.4 cm; median: 13 cm).6-months and 1-year patient and graft survival were 85 % (11/13) and 77 % (10/13), respectively. Reasons for graft loss and patient death were necrotizing enterocolitis, severe, muromonab-resistent, acute rejection, and graft ischemia due to complex coagulopathy. All other patients had good long-term outcome. They received enteral nutrition at six hours after operation and were persistently off total parenteral nutrition (TPN) by week two after ITx.ITx as established in our centre, with 1-year-patient and graft survival rates of 77 %, reflects current international standard. ITx is complementary to conservative and other operative methods of treating SBS. Referral and indication criteria need wider dissemination to prevent life-threatening complications of TPN.

The short bowel syndrome is caused by the anatomical or functional loss of more than 75% of the small bowel. These patients are currently dependent upon long-term total parenteral nutrition (TPN), a treatment that has made much progress, but which is not devoid of complications and which alters the quality of life. Transplantation of a new bowel is the only curative treatment for this disease. But intestinal transplantation (Itx) is not yet considered as an alternative to TPN. Itx is rendered difficult by the immunological obstacles, in particular a vigorous rejection response and the capacity of the bowel graft to induce a graft-versus-host disease (GVHD). Currently only profound and chronic immunosuppression is capable of controling this alloimmune response, but this is at the cost of infection, lymphoma and direct drug toxicity. For this reason Itx is currently rarely performed and usually seen as a "last chance" treatment for terminal patients with life-threatening complications of TPN. The last 10 years, there has been much research performed on Itx. Rejection and GVHD have been better characterized in small and large animal models. Some mechanisms of this alloimmune response have been delineated. Reproducible surgical techniques have been developed in large animal models. Immunomodulatory strategies have been developed that can help to control rejection and reduce the need for immunosuppression. The lessons learned from these experiments--in particular the surgical models that were developed and the immunomodulatory strategies that were designed--were applied in a clinical Itx programme. In October 2000 and in June 2002, 2 Itx were performed in patients with a short bowel syndrome and life-threatening liver failure caused by TPN. Both patients are doing well and have developed no episode of rejection or GVHD so far. This is despite the fact that they are receiving extremely low immunosupppression for this type of transplant. Currently those 2 patients are physically completely rehabilitated and can eat normally again.

The individual bioavailability of enterally administered drugs is usually uncertain in case of reduced bowel length. Routine measurements of plasma concentrations are available only for a small number of drugs. The daily dose recommended by the manufacturers may result in subtherapeutic plasma concentrations when given to such patients.In 2 patients with hemodynamically relevant atrial fibrillation and reduced gut length application of increasing sotalol doses was initiated. For the assessment of the individual bioavailability plasma concentrations were measured via HPLC immediately before and 2 hours after enteral application of sotalol. Judging by clinical criteria both patients were treated successfully. Even in the patient with severe short bowel syndrome (stomach, duodenum and 50 cm jejunal remnant) doubling of the daily dose led to a substantial increase in plasma concentrations.Effective enteral medication with sotalol in patients with short residual bowel is possible. Normal plasma concentrations can be achieved by administering doses according to the manufacturers' instructions. In case of severe short bowel syndrome, the measurements of plasma concentrations may be beneficial in supervising dose-adjustment.

In addition to psychological stress, stomas may lead to metabolic consequences. Colostomies normally cause only minor physiological problems; however, patients with ileostomies are at risk for severe metabolic disturbances. The small intestine essentially manages the balance of water and electrolytes and the absorption of nutrition. In special circumstances such as "high output" or short-bowel syndrome, dangerous consequences like kidney disorders may arise. Basic therapeutic strategies such as enteral or parenteral substitution are discussed.

Prematures and neonates with stomas have a high risk of developing sepsis by bacterial translocation, particularly when combined with parenteral nutrition. We studied a group of 35 newborns where split ileo- or jejunostomas were implanted in their first week of life. To prevent the development of a non-used distal bowel and a short bowel syndrome, the proximal bower content was transferred into the aboral stoma via the new continuous extracorporal stool transport (CEST) technique a few days after surgery. By using CEST the sepsis rate was reduced from 9 (without CEST) to only 0.8 cases of sepsis in 1000 days.

In most cases a short-bowel syndrome is the consequence of extensive bowel resection for Crohn's disease with loss of gastrointestinal function. After operation the patients should be adapted to enteral feeding as soon as possible. The nutritional management is determined by the type of intestinal resection and length of remaining small and large bowel. Total parenteral nutrition for life-time is necessary in patients with less than 50 cm of small bowel. Toxic megacolon is a rare complication seen in Crohn's disease. Conservative therapy includes high doses of intravenous steroids, electrolyte replacement and hydration, antibiotics, decompression of the bowel as well as vigorous surveillance for potential complications. About 50% of the patients with toxic megacolon recover with conservative treatment alone. Surgical intervention should be performed not later than 48 hours after unsuccessful conservative therapy.

Short-bowel syndrome is a rare problem in surgical practice and its prognosis depends on the length of intestinal remnants and/or the presence of a jejunostomy. In adults long-term total parenteral nutrition (TPN) can be avoided if the remaining small bowel is longer than 60-100 cm. In all, 50-60% of patients in the long-term follow-up are expected to be adequately nourished with oral feeding, 25% with enteral and parenteral feeding and less than 20% depend on long-term TPN alone. By using a modified diet (glutamine, growth hormone), intestinal absorption and overall prognosis could even be enhanced. The introduction of home TPN by specialized centres has resulted in a remarkable improvement in quality of life (80% good). The main complications of long-term TPN are sepsis, thrombosis and metabolic disorders. Medical therapy of diarrhoea consists of H2-receptor antagonists (hypergastrinaemia), loperamide and secretion inhibitors (somatostatin). Several surgical procedures have been performed, either to decelerate intestinal transit or to increase the area of intestinal absorption with overall unsatisfactory results. However, in the presence of small-bowel dilatation, promising surgical results (tapering, stricturoplasty, intestinal lengthening) have been achieved. There may be advances (immunosuppression) in the future that will make intestinal transplantation a good option for some patients; at present, the 1-year patient and graft survival in around 100 patients was 60% and 40%, respectively.

The short bowel syndrome represents the pathophysiological and clinical consequences, following extensive resection or loss of specific function of small intestine, failing adequate comensatory mechanismus. Present therapeutic options allow such patients an acceptable lifestyle. In selected cases, reintroduction into gainful employment becomes feasible. The prolonged adaptive process necessitates interdisciplinary therapeutic efforts, including medical, nutritional, social and psychological approaches. Suitably equipped rehabilitationcentres can successfully handle a considerable proportion of these measures, especially in the framework of an in-patient rehabilitation treatment programme. This article summarizes the physiology, pathophysiology, adaptive mechanisms, clinical picture and presents therapeutic options. In conclusion, sociomedical viewpoints are being discussed.

After massive intestinal resection resulting in short bowel syndrome it is often unclear if the patient will remain on total parenteral nutrition (TPN) or regain enteral autonomy. Small bowel transplantation or bowel-lengthening procedures could potentially be a therapeutic option for patients confined to life-long parenteral nutrition. Initiated early in the course of the disease this could prevent frequent serious complications of long-term parenteral nutrition. However, it is unclear which factors determine the outcome of these patients. For further information on the long-term prognosis, data of 33 patients with short bowel syndrome operated in our institution from 1982 to 1995 were retrospectively analyzed and the present status of all living patients evaluated. Gender, age or underlying disease had no influence on the adaptation of the small intestine or the duration of TPN in the surviving patients. Return to enteral autonomy mainly depended upon the length of the remaining small and large bowel. Thus the further course of the disease can be predicted and necessary measures can be taken as this information is always available at the time of initial surgery.

Massive small bowel resection results in a short bowel syndrome, characterized by malabsorption, weight loss, diarrhea and steatorrhea. Different surgical techniques have been used to slow down intestinal transit time or to increase the area of absorption. Techniques for the deceleration of intestinal transit are reconstruction of the ileocecal-valve, antiperistaltic intestinal segments, colon interposition, recirculating intestinal loops and intestinal pacing. For increase of the area of absorption growth of neomucosa, mucosal autotransplantation, intestinal lengthening and small bowel transplantation have been performed. All these procedures are still at different experimental levels. Due to inconsistent results so far the surgical therapy of the short bowel syndrom cannot be recommended for routine use. However, some techniques offer hope of a successful surgical development.

Mesenteric vascular occlusion with intestinal infarction is often regarded as a fatal illness. Often the diagnosis of severe ischemia is made during laparotomy. Sometimes resection is not performed because the conditions is thought to be incurable, and in such cases the mortality is 100%. If radical and aggressive resection is carried out even at the site of almost complete small bowel infarction and followed by an elective second-look operation, survival can be achieved in some patients. The motivation to attempt treatment should be further enhanced by the observation that the short-bowel syndrome following resection can be successfully treated, giving an acceptable quality of life for the patients. Between 1 January 1979 and 31 December 1979 we treated 9 male and 6 female patients with short-bowel syndrome after mesenteric occlusive disease; their ages ranged between 4 and 78 years, and the total duration of parenteral nutrition was 30,494 patient-days. With a median of 1503 days, the longest individual periods of parenteral nutrition were 4,919 and 5,015 days. We show the problems of long-term parenteral nutrition, including catheter-associated and nutritional complications, with reference to the individual courses of patients with short-bowel syndrome after mesenteric infarction. Despite some problems, patients of all ages can return to near-normality with an acceptable quality of life with the aid of parenteral nutrition at home.

Treatment of noninfectious diarrhea consists in unspecific and symptomatic measures as well as in specific dietetic or pharmacologic treatment. With respect to the latter, diet in primary gluten enteropathy and lactose malabsorption as well as antibiotic treatment in Whipple's disease and bacterial colonization of the small bowel are of importance. In addition, specific treatment directed to endocrine or other causes of the disease may be necessary, similar to the different causes of maldigestion. Here, in particular, substitution of pancreatic enzymes in pancreatic insufficiency is of importance.

In order to evaluate functional results and outcome of "limited surgery" in Crohn's disease we reviewed the data of 161 operations performed in 65 patients. In our series most of the patients had repeated operations. Nevertheless we saw no short bowel syndrome, no death occurred. Correlation was high between number of operations and length of resected bowel (r = 0.8) whereas no correlation was found between resected bowel and duration of disease nor between duration and number of operations. In conclusion strictly admitted principles of limited surgery seem to preserve good functional results. Risk of complications or short bowel syndrome seems not to be increased.

For two years after surgical small-intestine duplication a 9-year-old boy with the short bowel syndrome had recurrent acidosis which caused severe failure to thrive. During the acidotic crises he had behavioural disorders, unsteady gait, indistinct speech, lid raising weakness with vision paresis and occasional somnolence. These signs disappeared after the aciduria had been treated with high doses of bicarbonate. D-lactic acidosis was finally diagnosed by simultaneously determining D-lactate (8.9 mmol/l [normal0.5]) and L-lactate (1.4 mmol/l [normal1.78]) during an episode of aciduria (pH 7.3, base excess -11.8 mmol/l). Further acidotic crises were prevented by a carbohydrate-modified diet, on which he gained 8 kg in one year.

A Short bowel was induced in 8 beagle bitches by resecting 85% of the small intestine. Following resection, a tangential fixation was performed in antiperistaltic direction between the ileum and the proximal colon. A 15 cm segment of the remaining ileum was incised opposite to its mesenterial attachment and sewn onto the serosa of the neighboring segment of colon (Serosa patching). After 20 weeks of observation, segments of the ileum, the colon and the anastomosed intestinal segment were removed. The neomucosa covering the patch surface was investigated using immunohistochemical methods in order to demonstrate the presence of nerve fibers. The immunofluorescence reaction using anti-GFAP (glial fibrillary acidic protein) clearly demonstrated immunoreactivity in the formed neomucosa and in the underlying granulation tissue. The immunoreactive fibers were comparable with fibers demonstrated in the original mucosa. This finding is an indication that the neomucosa of a serosa patch may be functionally intact because the presence of nerves suggests that mucosal functions, e.g. resorption and secretion, are under nervous regulation.