Autologous Reconstruction and Visceral Transplantation for Management of Patients With Gut Failure After Bariatric Surgery

20 Years of Experience

Kareem M. Abu-Elmagd, MD, PhD, FACS; Guilherme Costa, MD, PhD; David McMichael, BA; Ajai Khanna, MD, PhD; Ruy J. Cruz, MD; Neha Parekh, RD; Masato Fujiki, MD; Koji Hashimoto, MD, PhD; Cristiano Quintini, MD; Darlene A. Koritsky, RN, BSN; Matthew D. Kroh, MD; Hiroshi Sogawa, MD; Ahmed Kandeel, MD; Jose Renan da Cunha-Melo, MD; Ezra Steiger, MD; Donald Kirby, MD; Laura Matarese, PhD; Abdullah Shatnawei, MD; Abhinav Humar, MD; Matthew R. Walsh, MD; Philip R. Schauer, MD; Richard Simmons, MD; Timothy Billiar, MD; John Fung, MD, PhD

Disclosures

Annals of Surgery. 2015;262(4):586-601. 

In This Article

Abstract and Introduction

Abstract

Objective: Bariatric surgery (BS) is currently the most effective treatment for severe obesity. However, these weight loss procedures may result in the development of gut failure (GF) with the need for total parenteral nutrition (TPN). This retrospective study is the first to address the anatomic and functional spectrum of BS-associated GF with innovative surgical modalities to restore gut function.

Methods: Over 2 decades, 1500 adults with GF were referred with history of BS in 142 (9%). Of these, 131 (92%) were evaluated and received multidisciplinary care. GF was due to catastrophic gut loss (Type-I, 42%), technical complications (Type-II, 33%), and dysfunctional syndromes (Type-III, 25%). Primary bariatric procedures were malabsorptive (5%), restrictive (19%), and combined (76%). TPN duration ranged from 2 to 252 months.

Results: Restorative surgery was performed in 116 (89%) patients with utilization of visceral transplantation as a rescue therapy in 23 (20%). With a total of 317 surgical procedures, 198 (62%) were autologous reconstructions; 88 (44%) foregut, 100 (51%) midgut, and 10 (5%) hindgut. An interposition alimentary conduit was used in 7 (6%) patients. Reversal of BS was indicated in 84 (72%) and intestinal lengthening was required in 10 (9%). Cumulative patient survival was 96% at 1 year, 84% at 5 years, and 72% at 15 years. Nutritional autonomy was restored in 83% of current survivors with persistence or relapse of obesity in 23%.

Conclusions: GF is a rare but serious life-threatening complication after BS. Successful outcome is achievable with comprehensive management, including reconstructive surgery and visceral transplantation.

Introduction

Over the last 2 decades, the field of human body energy and homeostasis has witnessed simultaneous evolution of bariatric surgery (BS) for morbid obesity and surgical rehabilitation for gut failure (GF).[1–12] For more than half a century, both modalities have experienced waves of enthusiasm and despair. With better understanding of gut homeostasis and the introduction of innovative surgical techniques, the 2 specialties have recently gained a respectable place in the surgical armamentarium.

With the seeds of surgical weight loss procedures implanted in 1960s, BS has recently grown to be one of the most common surgical procedures performed worldwide.[13–15] The introduction of new modalities with advances in laparoscopic technology has significantly improved the procedure's therapeutic indices and increased its global popularity.[2,5,7,8] These tremendous achievements were desperately needed because of the growing worldwide epidemic of morbid obesity with its detrimental impact on human health, cost of health care, and world economy.[16] In addition to effective long-term control of severe obesity, a new therapeutic dimension has been recently revealed with substantial restoration of glucose homeostasis signaling the metabolic advantages of these procedures.[17,18]

The concept of gut rehabilitation was born in late 1960s with the development of total parenteral nutrition (TPN) as a life-saving therapy for patients with GF.[19] The 1990s clinical introduction of intestinal transplantation was the second most important milestone in the evolution of such a challenging field.[20–24] Subsequently, growing interest in other alternative therapeutic modalities have been observed, including optimization of TPN therapy, utilization of new enterocyte growth factors, autologous reconstruction, and bowel lengthening.[10–12,25,26]

Despite well-documented therapeutic efficacy, BS can be associated with life-threatening complications.[27–33] Conceivably, long-term loss of nutritional autonomy could develop in some of these patients due to disruption of gut homeostasis.[34–37] As a result, a multifaceted deleterious effect on survival, psychosocial milestones, and economic metrics is anticipated with erosion of the overall value of health care.

This study addresses the surgical complexity and management of patients with GF after BS. The utilized surgical modalities including visceral transplantation were described in the milieu of the GF pathophysiology. The introduced surgical techniques stemmed from challenges confronted by the primary author in patients with complex abdominal pathology compiled with cumulative experience in the technical evolution of visceral transplantation. Despite the rare development of such a life-threatening complication after BS, this study adds a new dimension to the surgical management of most patients with different complex abdominal and gastrointestinal pathology. A new classification defining the different types of GF has also been introduced with novel applicable surgical techniques to restore gut homeostasis and nutritional autonomy.

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