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Background: Spring-mediated intestinal lengthening has been studied in numerous animal models to effectively achieve up to a 3-fold increase in length. In this study we are interested in optimizing this method of spring lengthening., Methods: Juvenile mini-Yucatan pigs underwent laparotomy for spring implantation. Springs were secured by plicating the intestine around the springs. In one set of experiments, varying degrees of plication were compared to determine the necessary narrowing needed to confine the spring. In another set of experiments, dissolvable sutures were used for the plication to allow for spontaneous spring passage postoperatively. Intestinal segments were retrieved and evaluated for lengthening and histological changes., Results: Pigs tolerated their diet advancement to a regular diet postoperatively. 10% plication resulted in a 1.3-fold increase in length, while 50% plication resulted in a 2.7-fold increase in length (p<0.05). At two months postoperatively, the majority of springs had safely passed out of the intestine. All lengthened intestine showed significant growth histologically., Conclusions: A 50% reduction in lumen diameter achieves optimal spring-mediated intestinal lengthening. Springs can safely pass out of the intestine, thus avoiding a second operation for spring removal. These results may be important in developing future therapies for short bowel syndrome., Level of Evidence: Level I experimental study., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Intestinal circumferential expansion is essential for bowel lengthening in patients with Short Bowel Syndrome. We hypothesized use of an endoluminal osmotic hydrogel expander (EOHE) as a novel approach for intestinal expansion. An EOHE was introduced into an isolated intestinal segment of New Zealand rabbits, with a similar segment created as a control. After 4weeks, the segments were retrieved for analysis. Weight, inflammatory markers and fluoroscopy data was recorded weekly. EOHE allowed successful expansion of intestinal segments from 4.68 ± 0.35 to 9.79 ± 0.35 cm (p = 0.01). Increase in intestinal length was 167.8 ± 35.21% in segments with EOHE vs. 23.03 ± 4.2% in the control group (p < 0.01). A significant intestinal dilatation (214.4 ± 1.58 vs. 34.59 ± 1.23%, p < 0.01) was demonstrated. Hematoxylin and eosin stain revealed conservation of intestinal architecture with muscle hypertrophy and flattening of the epithelium possibly due to compression. No reduction of rabbit weight, inflammatory markers or liver damage was described. EOHE appears to produce safe intestinal expansion, achieving increased length and dilatation suitable for lengthening procedure. This approach may allow development of similar techniques to expand bowel in short bowel patients. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 1304-1309, 2019., (© 2018 Wiley Periodicals, Inc.)

Background: Short bowel syndrome is a condition with substantial morbidity and mortality, yet definitive therapies are lacking. Distraction enterogenesis uses mechanical force to "grow" new intestine. In this study, we examined whether intestinal plication can be used to safely achieve spring-mediated intestinal lengthening in a functioning segment of jejunum in its native position., Methods: A total of 12 juvenile, miniature Yucatan pigs underwent laparotomy to place either compressed springs or expanded springs within a segment of jejunum (n = 6 per group). The springs were secured within the jejunum by performing intestinal plication to narrow the intestinal lumen around the spring. After 3 weeks, the jejunum was retrieved and examined for lengthening and for histologic changes., Results: There were no intraoperative or postoperative complications, and the pigs tolerated their diets and gained weight. Segments of jejunum containing expanded springs showed no significant change in length over the 3 weeks. In contrast, jejunum containing compressed springs showed nearly a 3-fold increase in length (P < .001). Histology of the retrieved jejunum showed a significant increase in thickness of the muscularis propria and in crypt depth relative to normal jejunum., Conclusion: Intestinal plication is effective in securing endoluminal springs to lengthen the jejunum. This approach is a clinically relevant model because it allows for normal GI function and growth of animals during intestinal lengthening, which may be useful in lengthening intestine in patients with short bowel syndrome., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Spring-mediated distraction enterogenesis has been shown to increase the length of an intestinal segment. The goal of this study is to use suture plication to confine a spring within an intestinal segment while maintaining luminal patency to the rest of the intestine., Methods: Juvenile mini-Yucatan pigs underwent placement of nitinol springs within a defunctionalized Roux limb of jejunum. A 20 French catheter was passed temporarily, and sutures were used to plicate the intestinal wall around the catheter at both ends of the encapsulated spring. Uncompressed springs placed in plicated segments and springs placed in nonplicated segments served as controls. The intestine was examined approximately 3 weeks after spring placement., Results: In the absence of plication, springs passed through the intestine within a week. Double plication allowed the spring to stay within the Roux limb for 3 weeks. Compared to uncompressed springs that showed no change in the length of plicated segments, compressed springs caused a significant 1.7-fold increase in the length of plicated segments., Conclusions: Intestinal plication is an effective method to confine endoluminal springs. The confined springs could lengthen intestine that maintains luminal patency. This approach may be useful to lengthen intestine in patients with short bowel syndrome., Level of Evidence: Level I Experimental Study., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: Techniques of distraction enterogenesis have been explored to provide increased intestinal length to treat short bowel syndrome (SBS). Self-expanding, polycaprolactone (PCL) springs have been shown to lengthen bowel in small animal models. Their feasibility in larger animal models is a critical step before clinical use., Methods: Juvenile mini-Yucatan pigs underwent jejunal isolation or blind ending Roux-en-y jejunojejunostomy with insertion of either a PCL spring or a sham PCL tube. Extrapolated from our spring characteristics in rodents, proportional increases in spring constant and size were made for porcine intestine., Results: Jejunal segments with 7mm springs with k between 9 and 15N/m demonstrated significantly increased lengthening in isolated segment and Roux-en-y models. Complications were noted in only two animals, both using high spring constant k>17N/m. Histologically, lengthened segments in the isolated and Roux models demonstrated significantly increased muscularis thickness and crypt depth. Restoration of lengthened, isolated segments back into continuity was technically feasible after 6weeks., Conclusion: Self-expanding, endoluminal PCL springs, which exert up to 0.6N force, safely achieve significant intestinal lengthening in a translatable, large-animal model. These spring characteristics may provide a scalable model for the treatment of SBS in children., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: Distraction enterogenesis has been investigated as a novel treatment for patients with short bowel syndrome (SBS) but has been limited by loss of intestinal length during restoration and need for multiple bowel surgeries. The feasibility of in-continuity, spring-mediated intestinal lengthening has yet to be demonstrated., Methods: Juvenile mini-Yucatan pigs underwent in-continuity placement of polycaprolactone (PCL) degradable springs within jejunum. Methods used to anchor the spring ends to the intestine included full-thickness sutures and a high-friction surface spring. Spring constant (k) was 6-15N/m. Bowel was examined for length and presence of spring at 1 to 4weeks., Results: Animals tolerated in-continuity lengthening without bowel obstruction for up to 29days. In-continuity jejunum with springs demonstrated intestinal lengthening by 1.47-fold ±0.11. Five springs had detached prematurely, and lengthening could not be assessed. Histologically, in-continuity jejunum showed significantly increased crypt depth and muscularis thickness in comparison to normal jejunum., Conclusion: Self-expanding endoluminal springs placed in continuity could lengthen intestine without obstruction in a porcine model. This is the first study showing safety and efficacy of a self-expanding endoluminal device for distraction enterogenesis. This is proof-of-concept that in-continuity spring lengthening is feasible and demonstrates its therapeutic potential in SBS., Level of Evidence: Level 3., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: Current models of mechanical intestinal lengthening employ a single device in an isolated segment. Here we demonstrate that polycaprolactone (PCL) springs can be deployed in-series to lengthen multiple intestinal segments simultaneously to further increase overall intestinal length., Methods: A Roux-en-y jejunojejunostomy with a blind Roux limb was created in the proximal jejunum of rats. Two encapsulated 10-mm PCL springs were placed in-series into the Roux limb and were secured with clips. After 4weeks, the lengthened segments were retrieved for histological analyses., Results: Lengthening two intestinal segments simultaneously was achieved by placing two PCL springs in-series. The total combined length of the lengthened segments in-series was 45±4mm. The two jejunal segments with PCL springs (25±2 and 20±2mm) were significantly longer than control segments without the spring (14±1mm, p<0.05)., Conclusion: Spring-mediated lengthening can be achieved using multiple springs placed sequentially. The use of the Roux-en-y surgical model allowed easy insertion of springs in a blind Roux limb and arrange them in-series. Combined with relengthening techniques, we can use these methods to increase the length of small intestine to reach clinical significance., Level of Evidence: 1 Experimental., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Case Report: Gastroschisis is the most frequent congenital abdominal wall defect. When associated with intestinal atresia (complex gastroschisis), short bowel syndrome may occur. Complicated gastroschisis is the most frequent cause of short bowel syndrome in our series. The serial transverse enteroplasty procedure has been used to lengthen the bowel and achieve intestinal rehabilitation in patients with dilated gut. The use of this technique in the newborn period, for tailoring the bowel while preserving absorptive mucosa, has been recently described. We present a video showing the surgical treatment of an intestinal obstruction produced by a complex intestinal atresia in a newborn baby in whom a primary closure of a gastroschisis had been done at birth. During laparotomy at the 21st day of life, a type IVa intestinal atresia was found, associated with a colonic stenosis. Proximal dilated jejunum was tailored with a serial transverse enteroplasty procedure, as shown in the video. End-to-end jejunal-ileal anastomosis was performed. Postoperative entero-cutaneous fistula occurred and was treated with vacuum-assisted therapy. Enteral feedings were initiated at 15 days after surgery. Parenteral nutrition was withdrawn at 30 days. After 16 months follow-up, actual weight was 8.7 kg (percentile 10% to 25%). The patient remained on full enteral feedings., Conclusions: In cases of intestinal atresia, short bowel syndrome, and proximal dilated bowel, we propose an aggressive surgical approach to preserve bowel mucosal surface while tailoring the jejunal loop to improve motility. The serial transverse enteroplasty procedure is an acceptable alternative to tailoring methods that resect a segment of the bowel wall., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: Previous methods of distraction enterogenesis have relied upon blind-ending intestinal segments or transmural device fixation, requiring multiple operations and potential bowel injury. We hypothesized that using a novel attachment would allow reversible device coupling to the luminal bowel surface, achieving effective endoluminal distraction., Methods: A telescopic hydraulic device was designed with latex balloon attachments covered with high-friction mesh and a dilating fenestrated elastic mask (DFM attachment), allowing mesh-to-mucosa contact only with inflation. Yorkshire pigs underwent jejunal Roux-en-Y limb creation and device placement via jejunostomy. Devices underwent 3 cycles of balloon inflation and hydraulic extension/retraction per day for 7 days and then explanted and studied for efficacy., Results: DFM attachment allowed reversible, high-strength endoluminal coupling without tissue injury or reduction in bowel perfusion. After 7 day implant, distracted bowel achieved a 44 ± 2% increase in length vs. fed, nondistracted bowel, corresponding to a gain of 7.1 ± 0.3 cm. Distracted bowel demonstrated increased epithelial cell proliferation vs. control bowel. Attachment sites demonstrated villus flattening, increased crypt depth, thicker muscularis mucosa, and unchanged muscularis propria thickness vs., Conclusion: Novel high-strength, reversible attachments enabled fully endoluminal distraction enterogenesis, achieving length gains comparable to open surgical techniques. This approach may allow development of clinically applicable technology for SBS treatment., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Jejunal atresia with short bowel syndrome is an unusual type of jejunoileal atresia. They present with jejunal atresia near the ligament of Treitz and a foreshortened small bowel. In this paper, we report our preliminary experience to emphasize the advantages and feasibility of enteroplasty for intestinal lengthening and primary anastomosis with an anterior flap in jejunal atresia with short bowel syndrome in neonates., Methods: Between January 2014 and December 2014, four neonates with jejunal atresia and short bowel syndrome were submitted to this procedure in our hospital. Enteroplasty for intestinal lengthening procedures was accomplished in all the neonates by laparoscopic-assisted procedure. The procedure was manually performed after exteriorization of the atretic bowel via the slightly enlarged umbilical port site incision., Results: The mean operative time was 80 min (range 65-110 min). Blood loss was minimal. There was no mortality or surgical complication so far. The median follow-up duration was 14.5 months (range 9-20 months). In all the cases, the autonomy for oral/enteric feeding was obtained within 1 month after surgery. One neonate was readmitted because of associated cholestasis 1 month after the operation, and was cured by conservative therapy., Conclusions: Enteroplasty for intestinal lengthening and primary anastomosis with an anterior flap is a safe and feasible technique that could allow increased tolerance to oral/enteric feeding, thereby improves their chances for quality survival.

Purpose: Currently, animal models used for mechanical intestinal lengthening utilize a single lengthening procedure prior to analysis or restoration back into continuity. Here we developed a novel surgical model to examine the feasibility of repeated lengthening of intestinal segments., Methods: A Roux-en-Y jejunojejunostomy with a blind Roux limb was created in rats. An encapsulated polycaprolactone spring was placed into a 1cm segment of the Roux limb. After 4 weeks, a second encapsulated PCL spring was inserted into a 1cm portion of the lengthened segment. After another 4 weeks, the repeatedly lengthened segments were retrieved for histological analyses., Results: Jejunal segments of the Roux limb were successfully lengthened from 1.0 cm to 2.6 ± 0.7 cm. Four weeks after the second PCL spring placement, 1.0 cm of the previously lengthened segment increased to 2.7 ± 0.8 cm. Stronger mechanical force was required to achieve subsequent re-lengthening. Lengthened and re-lengthened segments had increased smooth muscle thickness and crypt depth when compared to normal jejunal mucosa., Conclusion: Using the Roux-en-Y model, previously lengthened segments of intestine can be successfully re-lengthened. Intestinal segments may be subjected to multiple lengthening procedures to achieve clinically significant length for the treatment of short bowel syndrome., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: Current animal models of mechanical lengthening separate intestinal segments from enteric continuity. Such models are difficult to use for repeated lengthening procedures and result in intestinal tissue loss during restoration into continuity. We sought to create a novel surgical model to allow multiple lengthening procedures for the purpose of maximizing the net increase in tissue after intestinal lengthening., Methods: A Roux-en-y jejunojejunostomy with a 6-cm blind-ended Roux limb was created in the proximal jejunum of rats. Encapsulated 1-cm polycaprolactone springs were placed into the closed end of the roux limb and secured with a vessel loop. After 4weeks, lengthened segments and normal jejunum were retrieved for histologic analysis., Results: Jejunal segments were lengthened from 1.0cm to 3.0cm. Lengthened segments had increased smooth muscle thickness, fewer submucosal ganglia, and similar numbers of myenteric ganglia compared to normal intestine. When compared to normal jejunal mucosa, lengthened segments demonstrated unchanged villus height and increased crypt depth., Conclusions: We created an innovative surgical model for intestinal lengthening and successfully lengthened jejunal segments with a degradable spring. The Roux-en-y model may allow the use of a degradable spring for the treatment of short bowel syndrome., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: Distraction enterogenesis may provide a novel therapy for short bowel syndrome (SBS). Previously described methods have relied upon isolated intestinal segments or transmural fixation. Our objective was to develop a novel, fully endoluminal device, permitting placement and removal through an enteral stoma or orifice., Methods: A flexible device was designed consisting of two latex balloons mounted on coaxial catheters. The inner catheter allowed longitudinal force transmission from an external spring. Yorkshire pigs underwent jejunal Roux limb creation with device placement via jejunostomy. Balloons were inflated to 52 mmHg without significant reduction in bowel perfusion as measured by laser Doppler. The device was explanted after 7 days., Results: Distracted bowel achieved an increase in length of 26.1 ± 6.1 % vs nondistracted fed bowel. As the device resided in unfed bowel, a 66.7 ± 14.5% increase vs unfed bowel was noted. These corresponded to a gain of 6.3 ± 2.3 cm (0.9 ± 0.3 cm/day) and 12.9 ± 7.6 cm (1.8 ± 1.1 cm/day), respectively. Attachment sites demonstrated occasional epithelial sloughing with no balloon-associated perforation., Conclusion: A novel double-balloon catheter device allows for fully endoluminal distraction enterogenesis. This approach may allow development of clinically applicable technology for the treatment of patients with SBS.

Aim: Spiral Intestinal Lengthening and Tailoring (SILT) invented by our team is a new technique that offers minimal mesenteric handling and a more physiological result compared to the STEP procedure. Its feasibility has been tested in animal models and now we report the first successful human application in extreme short bowel syndrome., Materials and Methods: A 3-year-old girl suffered subtotal loss of her small bowel and ileocaecal junction as a result of midgut volvulus. Only 15 cm of jejunum remained intact. Parenteral nutrition (PN), gastrostomy feeding, controlled bowel expansion and SILT procedure were applied., Results: The length of the jejunum increased from the initial 15 to 22 cm during 12 months of PN and bowel expansion. Eleven centimeter of distended bowel was further lengthened up to 20 cm by SILT giving a total small bowel length of 31 cm. Oral and gastrostomy feedings were commenced 5 days postoperatively. There were no surgical complications 6 months after the procedure. The patient's liver function was preserved, she was weaned off PN, discharged from hospital, but remained on gastrostomy top up feeding. The net weight gain of the patient was 1,800 g 6 months after the procedure., Conclusion: SILT procedure is a safe and feasible technique for human intestinal lengthening and tailoring.

Introduction: Spiral Intestinal Lengthening and Tailoring (SILT) offers a new opportunity for the surgical treatment of short bowel syndrome. SILT requires less manipulation on the mesentery than the Bianchi procedure and does not alter the orientation of the muscle fibers like serial transverse enteroplasty (STEP). This study reports the first SILT results in a surviving animal model., Material and Methods: Vietnamese minipigs (n=6) underwent interposition of a reversed intestinal segment to produce proximal small bowel dilation. Five weeks later the reversed segment was resected, and the wall of the dilated intestine was cut spirally at 45°-60° to its longitudinal axis. The bowel was lengthened longitudinally, and the spiral shaped intestinal wound was sutured. Five weeks later, the animals were explored, and the lengthened segments were measured. Haematoxylin and eosin, picrosirius, neuron specific enolase, S-100, C-kit, and immunohistochemistry were performed., Results: Mean lengthening was 74.8% ± 29.5% and mean tailoring (lumen reduction) was 56.25% ± 18.8%. No instances of necrosis, perforation, suture break down, or peritonitis were observed in 6/6 animals. Four of six animals recovered uneventfully with viable lengthened segments. Statistical analysis showed no significant difference in length (p=0,078) and width (p=0,182) after 5 weeks. Two animals developed bowel obstruction due to narrowed lumen, adhesion, and strangulation after 14 and 24 days of surgery. In both animals the lumen was tailored by more than 70% to less than 1.5 cm diameter. The mucosa and the muscle layers in the operated segment had become hypertrophic, but the orientation of the circular and longitudinal muscle fibres remained normal after the SILT procedure. There were no signs of chronic ischemia or collagen accumulation after the SILT. The myenteric and submucosal plexuses and the Cajal cell network appeared normal., Conclusion: The bowel remained viable macroscopically and microscopically after SILT, such that SILT may be an alternative or an addition to the present technical repertoire of intestinal lengthening. However the limitations of tailoring should be kept in mind., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The serial transverse enteroplasty procedure (STEP) was introduced as a bowel-lengthening procedure to reduce complications related to short bowel syndrome (SBS). Although some have described it as a useful adjunct to the Bianci procedure, others have acknowledged it as a primary procedure. We present a case of jejunal atresia in which two STEP procedures were performed 7 months apart to increase small bowel length. A 1-day-old, term girl presented with a known bowel obstruction diagnosed in utero. A laparotomy revealed a Type IIIb jejunal atresia with no remaining small bowel or cecum. A STEP procedure with an end jejunostomy and ascending colon mucous fistula lengthened the small bowel from 35 to 50 cm. A repeat procedure 7 months later lengthened it to 89 cm. The STEP procedure results in slower intestinal transit time and increases enterocytes contact with oral intake. We performed it during our initial exploration to increase small bowel size by 30 per cent. A repeat procedure 7 months later increased length to 89 cm. The use of multiple, staged STEP procedures avoided the need for bowel transplantation and long-term total parenteral nutrition dependence, demonstrating its effectiveness as a primary procedure for the surgical management of SBS.

Background: In animal and human studies glucagon-like peptide-2 (GLP-2) has been shown to increase blood flow in the superior mesenteric artery and the portal vein. This study describes the effect of GLP-2 measured directly on the intestinal mucosal blood flow by laser Doppler flowmetry (LDF) in end-jejunostomy short bowel syndrome (SBS) patients., Methods: In five SBS patients with end-jejunostomy a specially designed laser Doppler probe was inserted into the stoma nipple, and blood flow measured directly on the jejunal mucosa for 105 min in relation to no treatment, systemic saline infusion, topical adrenaline application and a subcutaneous injection of 800 μg native GLP-2., Results: The GLP-2 injection increased jejunal mucosal blood flow by 79±37% compared to conditions, where no treatment was given (p<0.001). The significant effect was present at least 105 min. Systemic saline infusion and topical, mucosal adrenaline application did not affect mucosal microcirculation., Conclusions: GLP-2 raises jejunal microcirculation in SBS patients with end-jejunostomy. This may explain the redness and increase in the end-jejunostomy nipple size imminently after commencing GLP-2 injections. The potential beneficial effects of this GLP-2-mediated increase of blood flow in the mesenteric bed should be investigated in clinical conditions other than the short bowel syndrome., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Purpose: We previously demonstrated that it is feasible to lengthen intestinal segments with mechanical force and to restore them back into intestinal continuity. The changes in the enteric ganglia in the lengthened intestinal segments have not been described., Methods: A 1-cm segment of rodent jejunum was isolated from intestinal continuity and was lengthened using a spring. After lengthening, jejunal segments were either retrieved (n=4) or restored into intestinal continuity (n=4). Rats with restored segments were euthanized 2 to 3 weeks later. Ganglia were identified and quantified by immunostaining of histological sections., Results: The normal jejunum had 51 ± 5 myenteric and 31 ± 2 submucosal ganglia per circumferential tissue section. Lengthened segments had 21 ± 7 myenteric and 2 ± 2 submucosal ganglia. Restored segments had 46 ± 14 myenteric and 10 ± 10 submucosal ganglia. Circumferential density of ganglia followed a similar pattern., Conclusion: Mechanical lengthening led to a paucity of submucosal and myenteric ganglia. After restoration into continuity, the number increased toward normal, indicating regeneration of the enteric ganglia. The function of regenerated ganglia needs to be assessed in the future., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objectives: The aim of the present study was to investigate the segment- and time-related changes in rat short bowel syndrome and construct a 4-dimensional (4D) geometrical model of intestinal adaptation., Methods: Sprague-Dawley rats were divided into 3 groups: 2-day, 7-day, and 15-day postresection groups in which 75% of the jejunoileum was removed. Histological and morphometrical parameters in the remaining proximal to distal intestinal segments, from the jejunum to the distal colon, were comparatively evaluated in the groups. The data were used to construct a 4D geometric model in which villi were considered as cylinders, and their surface area was expressed as cylinder lateral area., Results: Major adaptive changes were observed in the ileum consisting of an increase in both the diameter of base and the height of villi. A parallel reduction in their number/mm was observed. The resulting ileal architecture was characterized by a limited number of large villi. An opposite pattern was observed in the jejunum whose postresection structure consisted of an increased number of villi. No changes were observed in the colon. Postresection restructuring was early and faster in the ileum than in the jejunum resulting in an increase in absorptive area of 81.5% and 22.5% in the ileum and jejunum, respectively., Conclusions: Postresection adaptation is intestinal segment-specific because all of the major changes occur in the ileum rather than in the jejunum. Sparing ileal segments during resection may improve the outcome of patients undergoing extensive intestinal resection. Our 4D model can be used to test interventions aimed at optimizing postresection intestinal adaptation.

Background: Interposition of a reversed jejunal loop in short bowel sydrome has previously been investigated in human along with animal models and seemed able to facilitate intestinal adaptation. However, it is unclear if growth hormone and insulin, well known for their implication in short bowel pathophysiology, intervene on this effect., Findings: Porcine models were randomly allocated to two cohorts: (1) short bowel (SB) group (n = 8) and (2) short bowel reverse jejunal segment (SB-RS) group (n = 8). Amongst other parameters serum growth hormone and insulin were measured at baseline, as well as on postoperative day 30 and 60., Conclusion: Both endogenous hormones failed to demonstrate significant difference in respect to potential direct effect to mechanisms of enhanced intestinal adaptation in reversed group.

An 8-year-old girl was admitted for severe electrolyte imbalance and for hyponatremic seizure. In July 2005, at 3 years of age, she underwent isolated small-bowel transplantation of 100 cm ileum from her father. Her own bowel was only 50 cm of proximal jejunum which had been directly connected to the anus due to extended total aganglionosis. The graft was placed into the middle of her remaining bowel, using the splenic artery and vein as feeding vessels with saving of the spleen. Daclizumab induction and tacrolimus monotherapy were applied for immunosuppression. Two acute cellular rejection episodes, E on day 10 and 4 years after transplantation, were successfully treated with OKT-3 and recombinant antithymocyte globulin, respectively. However, because of intermittent bowel dysfunction, she was hospitalized several times for hydration and metabolic care. On admission, her abdomen was moderately distended, and a simple abdominal film showed a fixed dilated loop. Colonoscopy could not pass the narrowed lumen, with stiffness at the anastomosis between the graft and the distal bowel. Endoscopic biopsy at the entrance to the stricture showed a nonspecific inflammatory reaction with fibrosis. Similar findings on a gastrograffin enema suggested chronic rejection (CR). On laparotomy, an irregularly narrowed fibrotic loop was noticed at the distal part of the graft, proximal to the anastomosis. We performed a 20-cm segmental resection with an end-to-end anastomosis. Histopathologic findings showed CR with fibrosis and hyalinization of the entire bowel wall and vessel walls with mild cellular infiltrations. She recovered in 10 days. The graft may have been saved, but intermittent requirement of hydration over the following months suggested progressive graft dysfunction. A case of segmental involvement of CR with subsequent successful graft salvage by partial resection is rare in the literature., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Significant bowel lengthening can occur in an isolated intestinal segment with the use of linearly directed distractive forces, resulting in increased surface area and epithelial cell proliferation. We hypothesized that reimplantation of this lengthened intestine into normal jejunum would preserve this gain in intestinal length and function similar to normal jejunum., Methods: An intestinal lengthening device was inserted into isolated jejunal segments in pigs, and fully expanded over 8 days. Lengthened segments were then reimplanted into normal intestinal continuity. Pigs were studied after another 28 days. Function was assessed by motility, mucosal enzyme activity, barrier function, and intestinal ion transport., Results: Lengthened segments were significantly longer than control segments and had nearly 2-fold greater surface area. Bowel lengthening was maintained 4 weeks after reimplantation. Motility after reimplantation was similar to nonoperated pigs. Barrier function, mucosal disaccharidase levels, and electrophysiologic measures declined immediately after lengthening but returned to nearly normal levels 28 days after reimplantation., Conclusion: Bowel lengthening results in a transient decline in mucosal absorptive function and smooth muscle contractility. However, function approaches that of normal bowel after reimplantation into enteric flow. These data may support the use of this technique as a potential new option for the treatment of patients with short bowel syndrome.

Purpose: Prior studies demonstrated the feasibility of lengthening intestinal segments with mechanical force, but no previous studies have restored the lengthened segment back into intestinal continuity., Methods: A 1-cm segment of isolated rat jejunum was lengthened using a Nitinol spring. After lengthening, this segment was restored into intestinal continuity via a transection of the intact small intestine. Rats were euthanized 2 weeks later to retrieve the restored intestinal segment for histologic and enzymatic analyses., Results: The isolated jejunal segments were initially lengthened to 3.3 ± 0.9 cm. After the lengthened segments were restored into intestinal continuity for 2 weeks, the final length of the restored segment was 1.9 ± 0.7 cm. All rats continued to gain weight, and the intestine proximal to the restored jejunal segment remained normal 2 weeks later. The restored jejunal segment had an increase in crypt depth and no difference in villus height compared with normal jejunum. Sucrase activity in the restored segment was not different from that in normal jejunum., Conclusion: Mechanically lengthened jejunum can be restored into intestinal continuity and appears to have normal function. This further demonstrates the feasibility of mechanical enterogenesis as a potential therapy for short bowel syndrome., (Copyright © 2011 Elsevier Inc. All rights reserved.)

A 22-year-old man suffered an acute small bowel infarct leading to extensive bowel resection, resulting in only 20 cm of jejunum to a jejunostomy, although he also had 50 cm of residual colon with a mucous fistula. The patient was out on long-term home parenteral nutrition (PN) but endured high stomal losses of 5-6 L per day and, despite all conventional measures, required 6.1 L of fluid (including PN) and 555 mmol sodium per day. Although body mass index was maintained, he suffered debilitating malaise and recurrent episodes of catheter-related sepsis and also developed persistently abnormal liver function tests. He was considered a potential intestinal transplant patient, but before taking that step, he opted for reanastomosis of his residual colon to his jejunum, ending in a colostomy. At surgery, only 30 cm of additional bowel lengthening could be achieved, but despite this, the patient's stomal losses reduced to 2.5 L per day, intravenous fluid requirements reduced to 4.1 L per day, and liver function normalized. The patient also gained 7.5 kg despite no change in PN caloric prescription, and his quality of life was dramatically enhanced. The case illustrates that even a small length of colon can grant significant improvements, probably via improvements in small bowel transit and adaptive changes, better sodium and water resorption with decreased hyperaldosteronism, and enhanced energy and nitrogen recovery. Reanastomosis of defunctioned colon should therefore always be considered a management option in short bowel syndrome.

Background: Small intestinal submucosa (SIS) is a porcine-derived, acellular, collagen-based matrix that has been tested without seeded smooth muscle cells (SMCs) for intestinal tissue engineering. We examined the expression patterns of contractile proteins of SIS with SMCs implanted in an in vivo rodent model., Materials and Methods: Intestinal SMCs were isolated from Lewis rat pups. Four-ply tubular SMCs-seeded SIS or blank SIS scaffolds were implanted in an adult rat jejunal interposition model. Recipients were sacrificed at 2, 4, and 8 wk following the implantation. The retrieved specimens were examined using antibodies against contractile proteins of SMCs., Results: Cultured intestinal SMCs expressed α-smooth muscle actin (α-SMA), calponin, and less smooth muscle myosin heavy chain (SM-MHC) in vitro. Cell-seeded SIS scaffolds contracted significantly over 8 wk of implantation but were comparable to SIS scaffolds without cell seeding. Implanted cell-seeded SIS scaffolds at 2 wk expressed extensive α-SMA, some calponin, and minimal SM-MHC. At 4 wk, α-SMA-expressing cells decreased significantly, whereas calponin or SM-MHC expressing cells were rarely detected. A small number of α-SMA-expressing cells were present at 8 wk, whereas more calponin or SM-MHC expressing cells emerged in proximity with the anastomotic interface., Conclusions: Cell-seeded SIS contracted significantly after implantation, but the expressions of contractile proteins were present at the site of SIS interposition. No organized smooth muscle was formed at the site of implantation. A better scaffold design is needed to produce structured smooth muscle., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: We tested the coupling portion of a prototype intraluminal distraction enterogenesis device to allow flow-through of simulated enteric contents (SEC) in both pig and human jejunum., Materials and Methods: SEC was made using 80% corn syrup. Ten-cm pig and human intestinal segments had a spoke-shaped 2.2 cm coupling adaptor sutured in place, intraluminally. The adaptor had a flow-through area of 33.6 mm(2). SEC was pumped into the proximal part of the intestinal segment at 0.083 mL/s. The times to first passage of SEC through the coupler (first drop), 10 mL, and 20 mL of SEC eluted from the distal end were recorded., Results: Mean time to first drop elution was 155 ± 38 s with pig, and 149 ± 22 s with human bowel (P = 0.8). This corresponded to a hydrostatic pressure of 37.5 mmHg before the initial drop passed through. Mean flow rates were 0.094 mL/s in pig bowel and 0.084 mL/s in human bowel (P = 0.09). To account for occlusion from luminal debris, a 75% occlusion of coupler holes was studied in the smaller pig bowel to investigate if reductions in flow-through area could be tolerated. Mean time to first drop increased slightly to 171 ± 15 s, but the elution rate stayed the same (P = 0.5)., Conclusions: After a physiologic level of initial pressure buildup allowing the first drop of SEC to pass the coupling adaptor, our prototype intestinal coupling adaptor did not obstruct flow-through of SEC, even after a 75% decrease in flow-through area. This type of attachment represents a viable approach to placing a device in-continuity without obstructing flow of enteric contents., (Copyright © 2011 Elsevier Inc. All rights reserved.)

We report successful fluoroscopically guided balloon dilatation of an early postoperative stricture of a jejunoileal anastomosis in a 3-month-old infant who underwent serial transverse enteroplasty for type IIIb apple peel intestinal atresia., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Purpose: Prior studies demonstrating the ability to lengthen intestinal segments with mechanical force required devices with extracorporeal components. The feasibility of using a completely implantable device for in vivo intestinal lengthening was evaluated in this study., Methods: Biocompatible Nitinol springs capable of 5-fold expansions were compressed using absorbable sutures and were implanted into isolated segments of proximal jejunum in rats. Springs compressed with nonabsorbable sutures served as controls. The animals were observed with serial abdominal x-rays until the springs became fully expanded. Intestinal segments were then retrieved for histologic analysis. Two-tailed and paired Student's t tests were used for statistical analysis., Results: Intestinal segments were successfully lengthened in the experimental group from 1.3 +/- 0.3 cm to 4.4 +/- 0.5 cm (P < .001). Maximum spring length was achieved on postoperative day 36 (range, 16-50 days). In the control group, there was also an increase in intestinal lengths, from 1.6 +/- 0.04 cm to 2.9 +/- 0.4 cm (P < .001) (Fig. 4). In percentages, a 250% increase in length was observed in the experimental group vs an 85% increase in the control group (P < .001). Microscopic evaluation of both control and experimental segments revealed gross preservation of intestinal architecture; however, muscular layer hypertrophy and villous atrophy were noted., Conclusions: Continuous mechanical force with an implantable spring successfully lengthened isolated segments of small bowel in an animal model. Although similar results have been demonstrated using other devices, the current device is totally implantable and may be deployed endoscopically., (Copyright 2010 Elsevier Inc. All rights reserved.)

Objective: Few infant animal models have been used to study infantile short bowel syndrome (SBS). Most SBS models involve removal of the proximal small bowel followed by jejunoileal anastomosis, which has unclear clinical relevance to human infantile SBS that often results from surgical treatment for necrotizing enterocolitis and involves removal of the ileum, ileocecal valve, and part of or the entire colon. Our objective was to develop a more appropriate SBS model in developing rats., Materials and Methods: Twenty-day-old weanling rats were divided into 2 surgery groups, ileocecal resection (ICR) and sham groups, and a control group that did not undergo surgery. All were fed a liquid diet ad libitum for 7 days after surgery or for 7 days in the controls, and body weight, food intake, and stool changes were recorded daily. The rats were then euthanized and intestinal lengths and weights were recorded. Samples of intestine from the distal jejunum and proximal colon were collected for histology. Mucosal samples from the middle, distal jejunum, and colon were collected for measurements of mucosal weights, DNA, RNA, and protein levels. Maltase activity was determined in the small intestine., Results: Eighty-five percent of rats survived the ICR with subsequent development of diarrhea, hyperphagia, and poor growth. Adaptive responses to ICR, as compared with sham, were evidenced by increased intestinal and mucosal weights, DNA, RNA, and protein levels, increased maltase activity and villous thickness in distal jejunum, and increased mucosal thickness in the colon., Conclusions: This ICR model in weanling rats is appropriate for studying human infantile SBS.

Background: The aim of this study was to assess early morphological changes of the residual small intestine 30 days after application of Benzalkonium Chloride (BAC) in a rat model of short bowel syndrome (SBS)., Materials and Methods: Twenty nine Wistar rats (260 +/- 20 g) underwent 80% midsmall bowel resection with end to end anastomosis. In group 1 (n=14) BAC solution 0.1% was applied to a 2 cm segment of jejunum, and in group 2 (n=15) normal saline was applied in a similar manner and the rats were sacrificed 30 days after operation. Specimens for histological examination were obtained initially and at sacrifice., Results: In the BAC treated jejunal segment (group 1), a statistically significant increase (p< 0.05) was noted in villous height by 33.2%, in crypt depth by 26.4%, in muscle thickness by 26%, 109.6% in intestinal diameter, and 20% in total intestinal length, compared to group 2., Conclusions: BAC application to the serosal surface of rat's jejunum in SBS is a simple method that within only 4 weeks can topically augment the natural adaptation process noticed following intestinal resection. Further research with a tapering technique performed in sequence is suggested, to prevent possible problems associated with pseudoobstruction in the long term.

Background: Some surgical pathologies eventually require intestinal resection. This may lead to an extended procedure such as leaving 30 cm of proximal jejunum and left and sigmoid colon. One of the most important consequences of this type of resection is "intestinal failure" or short bowel syndrome. This complex syndrome leads to different metabolic and water and acid/base imbalances, as well as nutritional and immunological challenges along with the problem accompanying an abdomen subjected to many surgical procedures and high mortality. Many surgical techniques have been developed to improve quality of life of patients., Methods: We designed a non-transplant surgical approach and performed the procedure on two patients with postoperative short bowel syndrome with <40 cm of proximal jejunum and left colon., Results: There are a variety of non-transplant surgical procedures that, due to their complex technique or high mortality rate, have not resolved this important problem. However, the technique we present in this work can be performed by a large number of surgeons. The procedure has a low morbimortality rate and offers the opportunity for better control of metabolic and acid/base balance, intestinal transit and proper nutrition., Conclusions: We consider that this technique offers a new alternative for the complex management required by patients with short bowel syndrome and facilitates their long-term nutritional control.

Purpose: To investigate the effects of intrinsic denervation of the jejunum after the extensive intestinal resection in rats., Methods: Thirty male Wistar rats were distributed into three groups, depending on the experimental procedure: Group C (control), Group R (resection) and Group D (resection plus denervation). The body weight gain and a histomorphometric study of the jejunal mucosa were performed., Results: The mean body weight of the group D animals showed a higher increase when compared to group R (D=312.2+/-21 g and R=196.7+/-36.2g). The number of jejunum myenteric neurons was smaller in group D (344.8+/-34.8 neurons/mm) when compared to other groups (R=909.0+/-55.5 and C=898.5+/-73.3). A hyperplasia of the jejunum mucosal epithelium was observed in the group D but also in the group R (R=7.3+/-3.9 mm2 and D=10.8+/-4.3 mm2), when compared to group C (C=5.8+/-3.0 mm2). The epithelial cell proliferation of the jejunum was higher in group D animals (48.7%) when compared to the other groups (R=31.9% and C=23.6%)., Conclusions: The denervated animals presented an increase the body weight gain and mucosal cell proliferation responses when compared to the control group. This experimental model may provide new strategies for the surgical treatment of the short bowel syndrome.

A rare case of short bowel syndrome combined with mechanical ileus due to numerous strictures of duodenum, a large part of the small and a half of the large bowel complicating radiotherapy after radical right nephrectomy for Wilms tumor 31 years ago was reported. The proximal 60cm of the jejunum were preserved only. A by-pass latero-lateral isoperistaltic retro-colonic gastrojejunoanal anastomosis was performed in combination with antiperistaltic interposition of 15cm of intact large bowel between the first proximal 40cm and the distal 20cm of the intact jejunum. The distal part of the intact jejunum was included in an isoperistaltic latero-lateral anastomosis with a normal colon segment. The success of the operative intervention depends on patient's age, intestinal residual, the presence of pre-stenosis dilatation, intestinal function and correctly selected surgical method to maintain the energy balance in the organism with oral feeding only.

Background: Low-fat diets (LFD) are utilized frequently in patients with short bowel syndrome (SBS). The purpose of this study was to investigate the effects of LFD on intestinal adaptation, enterocyte proliferation, and enterocyte cell death in a rat model of SBS., Methods: Adult male Sprague-Dawley rats were divided into 3 experimental groups: Sham-NC rats underwent bowel transection and reanastomosis and were fed normal chow (NC), SBS-NC rats underwent 75% small bowel resection and were fed NC, and SBS-rats were fed a low-fat diet (SBS-LFD). Parameters of intestinal adaptation, enterocyte proliferation, and enterocyte apoptosis were determined on day 14 after operation., Results: SBS-NC rats showed a significant increase (v Sham-NC) in jejunal and ileal bowel and mucosal weight, mucosal DNA and protein, villus height, and crypt depth. A significant 67% increase in crypt cell proliferation rate and 265% increase in villus enterocyte apoptosis was seen in the ileum of SBS-NC rats compared with control animals (P <.05). SBS-LFD animals showed lower ileal mucosal weight (29%; P <.05), jejunal crypt depth (20%; P <.05), and ileal villus height (21%; P <.05). A significant decrease in villus apoptosis in jejunum (74%; P <.05) and ileum (67%; P <.05) and a decrease in cell proliferation in ileum (35%; P <.05) was seen also after exposure to LFD compared with SBS-NC., Conclusions: In a rat model of SBS, early LFD appears to inhibit parameters of intestinal adaptation. A possible mechanisms for this effect may be decreased cell proliferation. Decreased enterocyte loss via apoptosis, found in this study, may reflect a reduced number of enterocyte.

Background/purpose: Although the bowel neovascularization by omentoenteropexy seems to be a good alternative to bowel lengthening, there were no rigorous analyses about its histologic structure and intrinsic innervation. The aim of this study was a histologic and immunohistochemical analysis of a neovascularized jejune segment (NJS) by omentoenteropexy., Methods: An NJS was done by omentoenteropexy in 13 Wistar rats. Seven weeks afterward, the mesentery of the NJS was ligated and divided. The NJS was separated from the normal jejunum by proximal and distal complete sections. End-to-end anatomosis was done between NJS and normal jejunum to restore bowel continuity. Twenty-six rats were sham operated. At 10 weeks, specimens were taken, and H&E, S-100 protein, and neuron-specific enolase staining were done. The muscle layer thickness, mucosae layer, and myenteric plexus were analyzed. The statistical tests were the Mann-Whitney test, Friedman's test, and Spearman's correlation., Results: There was a significant increase in NJS diameter. The muscle layers and mucosa were greater in the study group. The average number of neurons per intestinal ganglion was significantly fewer in the NJS., Conclusions: Omentoenteropexy provoked an increase in the diameter of NJS and contributed toward a reduction of the number of neurons in the myenteric plexus of NJS.

Background/purpose: Bowel lengthening may be beneficial for children with short bowel syndrome. However, current techniques require at least one intestinal anastomosis and place the mesenteric blood supply at risk. This study seeks to establish the technical principles of a new, simple, and potentially safer bowel lengthening procedure., Methods: Young pigs (n = 6) underwent interposition of a reversed intestinal segment to produce proximal small bowel dilation. Five weeks later the reversed segment was resected. Lengthening of the dilated bowel then was performed by serial transverse applications of a GIA stapler, from opposite directions, to create a zig zag channel. A distal segment of equal length served as an in situ morphometric control. Contrast radiologic studies were performed 6 weeks later, and the animals were killed. Statistical comparisons were made by paired t test with P less than.05 considered significant., Results: After bowel lengthening, all animals gained weight (66.7 +/- 3.0 [SD] kg v 42.5 +/- 3.5 kg; P <.001) and showed no clinical or radiologic evidence of intestinal obstruction. Intraoperatively, immediately after serial transverse enteroplasty, the intestine was substantially elongated (82.8 +/- 6.7 cm v 49.2 +/- 2 cm; P <.01). Six weeks after surgery, the lengthened intestinal segment became practically straight and, compared with the in situ control, remained significantly longer (80.7 +/- 13.1 cm v 57.2 +/- 10.4 cm; P <.01). There was no difference in diameter between these segments (4.3 +/- 0.7 cm v 3.8 +/- 0.4 cm; P value, not significant)., Conclusions: Serial transverse enteroplasty (STEP) significantly increases intestinal length without any evidence of obstruction. This procedure may be a safe and facile alternative for intestinal lengthening in children with short bowel syndrome., (Copyright 2003, Elsevier Science (USA). All rights reserved.)

Recombinant growth hormone (GH) has been used successfully to promote mucosal intestinal adaptation in adults with short bowel syndrome. Here the authors report the case of an infant with extreme short bowel syndrome successfully treated with intestinal lengthening and GH. The patient was born with intestinal atresia leaving only 12 cm of jejunum and 2 cm of ileum with ileocecal valve. A Bianchi procedure extended the length to 25 cm, but 6 months later she still received 50% of her nutritional requirements by parenteral route. A 4-week course of 0.5 U/kg of GH dramatically changed the situation allowing weaning of total parenteral nutrition (TPN) 2 weeks after the end of the treatment with striking nutritional improvement, decrease in the number of stools from 7 to 2 per day, and no secondary effects. The authors believe that GH deserves clinical trial in cases of extreme short bowel.

While small-bowel transplantation remains an option for the management of short-bowel syndrome (SBS), every effort must be made to optimize the function of the native bowel. This report describes a patient with SBS who dramatically improved after a Bianchi procedure. The patient was born with type IIIb jejunal atresia, complicated by volvulus of the terminal ileum. He was left with 40 cm of small bowel and his ileocecal valve. During the first 20 months of his life, he was always hospitalized except for 3 months. He was on parenteral nutrition (TPN) and suffered multiple episodes of central line sepsis. Massive small-bowel dilatation caused a functional bowel obstruction with bacterial overgrowth, and villous atrophy of the jejunal mucosa was discovered on biopsies done by colonoscopy. In March 1994, we elected to proceed with a Bianchi procedure. Thirty cm of jejunum were divided longitudinally. During the following year, his enteral tolerance steadily improved to the point where TPN could be discontinued. We conclude that pediatric surgeons should not hesitate to use this procedure in the management of SBS.

Objective: To evaluate the functional response, morbidity and histostructural changes in rats enterectomized and without cecum using two types of syngenic enteral transplants., Material and Methods: Controlled randomized surgical-therapeutic trial. Four groups of male Lewis rats 8-10 weeks old underwent the following procedures: 1. Lethal enteral resection (n = 10). 2. Lethal enteral resection + total yeyuno-ileal transplant (n = 28). 3. Lethal enteral resection + distal segmentary of 40% and cecum transplant (n = 32). 4. Control group (n = 10)., Results: 11% of the transplanted animals died due to technical failures; both transplanted groups had a similar proportion of late complications, mostly enteral obstruction. A persistent diarrhea was observed in 20% of the yeyuno-ileal transplanted group, but no significant differences were found between the two groups concerning survival, weight gain, protein and triglycerides serum levels, and a maltose absorption test; villus and crypt hypertrophy was observed in both grafts. The enteral graft integration was followed by structural changes similar to those found in intestinal remnants on deficit conditions after enteral resection., Conclusion: The bowel distal segmentary transplant with ileocecal valve and cecum may be a good option in cases of irreversible enteral failure, as the functional response and morbidity are similar to those found with the standard total transplant.

Basing on the establishment of an isolated bowel segement (IBS) in Beagle dog by omentoenteropexy, the possibility of using omentum as vascular pedicle in bowel elongation was investigated. Five young Beagle dogs (3 females, 2 males) with a body weight of 5-9 kg were used. A longitudinal incision (15 cm long) was made down to the seromuscular layer of the jejunal segment on the antimesenteric border, 20 cm distal to the duodenojejunal fold, the mucosal layer should never be injured. Then the free margin of the omentum was attached to the seromuscular border of the jejunum by interrupted sutures. One dog died from volvulus and necrosis of the bowel 3 days after operation. Seven weeks later, the mesentery was ligated in one dog and the bowel lengthening procedure was carried out in the other 3 dogs. The procedure consisted of longitudinal splitting of the isolated bowel segment anteroposteriorly, thus two separated segments of bowel were obtained, each received its own blood supply from either omental or mesenteric blood vessels. Either of the longitudinally splitting segments was rebuilt into one intestinal canal by 3/0 non-traumatic sutures. Then isoperistaltic end-to-end anastomosis of these two isolated segments was carried out, and an jejunostomy was established. The free jejunal ends were rejoined together to restore the continuity of the bowel lumen. Two weeks later, the blood supply of the experimental bowel segment was observed. It was shown that the IBS and elongated bowel segment (EBS) appeared viable, and there was good collateral circulation between the bowel segment and the omentum. The regeneration of lymphatics was observed from injection of methylene blue. It was concluded that a viable IBS and EBS could be established by using omentoenteropexy technique. The application of the this model in the management of short bowel syndrome needed to be further investigated.

Neonates and growing individuals have increased nutritional demands as compared with adults. To determine the functional ability of an intestinal graft to allow survival and growth, an otherwise lethal short gut model should be used (resection of both the entire small bowel and the cecum). In this study the authors investigated the survival and growth in young rats (80 to 125 g) with this lethal short gut syndrome (SGS) and either syngeneic or allogeneic segmental small bowel transplantation (SBTx). Additionally they sought to determine the effect of therapeutical doses of cyclosporine (CyA) in young, growing rats. To avoid total parenteral nutrition in rats undergoing SBTx, surgery was carried out in two steps: after segmental SBTx of a 25-cm jejunal graft, SGS was created 2 weeks later. Lewis rats underwent 1: Syngeneic segmental SBTx + SGS (n = 7); 2: Allogeneic segmental SBTx (donor: Lewis Brown Norway F1) + SGS + CyA (15 mg/kg/d for 7 days, then every other day for 21 days) (n = 9); 3: Syngeneic segmental SBTx + SGS + CyA as in group 2 (n = 5); 4: SGS alone (n = 5): 5: small bowel resection alone (n = 5); 6: sham laparotomy twice (n = 5); 7: sham laparotomy twice + CyA as in group 2 (n = 6). Weight, general condition, and nutritional serum variables were followed up regularly for 4 months. Rats with resection of small bowel survived but did not grow. Rats with small bowel resection + cecectomy died within 5 days.(ABSTRACT TRUNCATED AT 250 WORDS)

This study was undertaken to investigate whether two-stage segmental small bowel allotransplantation can maintain growth and development of young dogs (16 weeks, 5 to 6 kg) with surgically created short bowel syndrome (SBS). After near-total small bowel resection (group 1; n = 3), irreversible weight loss was noted. After a sham operation (group 2; n = 3), no growth disturbances were found. Major histocompatibility matched small bowel transplantation (SBT) with cyclosporine A as immunosuppressant, was performed in two stages (group 3; n = 7). During the first stage, one meter of jejunoileum from an adult donor was placed as a Roux loop. Four weeks later, the native small bowel was removed and replaced by the graft. Only one dog survived long-term; the dogs died from infectious complications. The addition of selective decontamination of the digestive tract and early gastrostomy feeding (group 4; n = 10) resulted in long-term survival in 60%. Follow-up at 4 months showed that their growth was about 20% compromised compared with that of the sham-operated animals. Functional analysis showed that electrolytes, urea, and D-xylose were normal, but there was an increase in the lactulose:mannitol ratio, fecal fat excretion, and postheparin diamine oxidase release. These results show that under the conditions described, segmental SBT functions sufficiently to treat SBS but does not maintain normal growth.

An isolated bowel segment (IBS) was created in dogs by omentoenteropexy, using staged procedures. (1) Omentoenteropexy was performed at the antimesenteric border of a 15-cm jejunal segment, which was exteriorized at both ends (IBSB). (2) After 6 weeks, once dual vascularization to the IBS had been established, its mesentery was divided (IBSA) or longitudinally split, thus achieving its elongation (IBSE). A control dog underwent a Thiry-Vella (T-V) loop procedure of an identical jejunal segment. Viability of the IBSB and IBSA was previously proven by the authors, through angiographic studies. In the present study, the absorption capability of IBS variants was assessed using in situ luminal perfusion, with a bicarbonate buffer containing glucose and labeled glycine. Jejunal transport rates of these solutes were calculated from the differences in their concentrations in the perfusion solution and in the effluent. Comparisons were made among the IBS variants and between them and the T-V loop. No significant difference in the absorption capability of glucose and glycine was noted between the various IBS variants. There was a marked reduction of glucose absorption and a moderate reduction of glycine absorption in all IBS variants. when compared with the fresh T-V loop, most probably because of disuse atrophy of the mucosa. In conclusion, absorption of glucose and glycine is preserved in the IBS, created by omentoenteropexy, both after its mesenteric division and following the IBS elongating procedure.

Background: Traditional therapy for short-bowel syndrome is long-term, expensive and inconvenient; it is often associated with high morbidity and mortality. Thus, there has been increasing interest in the surgical management of this syndrome. Intestinal lengthening is attractive not only because of tapering of the dilated intestine, but also for preserving the intestine that is tapered. The purposes of this study were (a) to develop a reproducible surgical technique for intestinal lengthening and (b) to assess the response of the lengthened jejunum to a short-gut situation., Methods: Fourteen pigs weighing 13-20 kg were chosen for the study. The animals were divided into three groups: Group I: two pigs received a 20 cm jejunum lengthening only; Group II: six pigs received an 80% bowel resection only; Group III: six pigs received an 80% bowel resection, followed by a 20 cm loop lengthening in the residual jejunum four to seven weeks later. All were observed for a period from 4 to 28 weeks., Results: All lengthened loops, of either primary lengthening (Group I) or delayed lengthening (Group III) functioned well and showed no clinical leakage. Three pigs in Group II (bowel resection only) died of malnutrition at the 5th, 10th and 19th postoperative week, respectively. Only one pig in Group III died, 67 days after bowel lengthening, from intestinal obstruction. During sacrificing laparatomy, two pigs in Group III were found to have side to side enteroenteral fistulae between the lengthened loops. The lengthened bowel was found to be normal histologically., Conclusions: These results proved that intestinal lengthening is technically feasible, and may be useful for patients suffering from surgical short-bowel syndrome and who have not been completely weaned off parenteral feeding.

An isolated bowel segment (IBS) was created in rats and dogs by a two-stage procedure. Initial coaptation of the bowel segment to the omentum ("omentoenteropexy") is followed by division of its mesentery several weeks later. The viability of the segment is maintained by angiogenesis at the coaptation site. Neoformed blood vessels were shown by angiographic studies, and in a dog the IBS was used for esophageal interposition.

Apple-peel jejunal atresia is a rare digestive tract congenital defect often accompanied with a short gut. Two cases managed by a three-stage medical and surgical approach are reported. A protein hydrolysate-jejunal secretion mixture was drip-fed through the distal ileostomy to stimulate trophicity of the distal gut.