Progress in intestinal adaptation after enterectomy / 中华胃肠外科杂志

Intestinal adaptation is a spontaneous compensation of the remanent bowel after extensive enterectomy, which improves the absorption capacity of the remanent bowel to energy, fluid and other nutrients. Intestinal adaptation mainly occurs within 2 years after enterectomy, including morphological changes, hyperfunction and hyperphagia. Intestinal adaptation is the key factor for patients with short bowel syndrome to weaning off parenteral nutrition dependence and mainly influenced by length of remanent bowel, type of surgery and colon continuity. In addition, multiple factors including enteral feeding, glucagon-like peptide 2 (GLP-2), growth hormone, gut microbiota and its metabolites regulate intestinal adaptation via multi-biological pathways, such as proliferation and differentiation of stem cell, apoptosis, angiogenesis, nutrients transport related protein expression, gut endocrine etc. Phase III clinical trials have verified the safety and efficacy of teduglutide (long-acting GLP-2) and somatropin (recombinant human growth hormone) in improving intestinal adaptation, and both have been approved for clinical use. We aim to review the current knowledge about characteristics, mechanism, evaluation methods, key factors, clinical strategies of intestinal adaptation.

The effect of ileocecal valve removal in a model of short bowel syndrome / Efeito da remoção da válvula ileocecal em modelo de síndrome do intestino curto

ABSTRACT Background : Short bowel syndrome is a harmful condition that needs experimental research. Aim: To assess the impact of the ileocecal valve removal in a model of short bowel syndrome, in order to investigate the evolution of the colon under this circumstance. Method: Fifteen Wistar rats were equitable divided into: Control (Sham), Group I (70% enterectomy preserving ileocecal valve) and Group II (70% enterectomy excluding ileocecal valve). After enterectomy was performed jejunoileal or jejunocecal anastomosis and sacrificed the animals on 30th postoperative day for histomorphometric study of the colon. During this period, was observed the clinical evolution of the animals weekly including body weight measurement. Results: Group I and II presented progressive loss of weight. In Group I was observed diarrhea, perineal hyperemia and purple color of the colon during autopsy. Histomorphometry assay showed hypertrophy and hyperplasia of colon mucosa in Group I. In Group II the colon wall was thicker due to hypertrophy and muscular hyperplasia, and in mucosa vascular proliferation and inflammatory infiltrate were intense. Conclusion : This short bowel syndrome model is relevant and achieve 100% of survival. Animal's weight loss was not altered by the presence or exclusion of the ileocecal valve. Animals with 70% of small bowel removal and presence of the ileocecal valve attained a better clinical evolution and histological colon adaptation than those without ileocecal valve.

RESUMO Racional: Síndrome do intestino curto é condição clínica crítica e que precisa de pesquisa experimental. Objetivo: Avaliar o impacto da remoção da válvula ileocecal em um modelo de síndrome do intestino curto para investigar o comportamento do cólon nesta circunstância. Método: Quinze ratos Wistar foram divididos em três grupos de cinco: Controle (Sham), grupo I (enterectomia de 70% com preservação da válvula ileocecal), e grupo II (70% enterectomia de 70% excluindo a válvula ileocecal). Após a enterectomia foi restabelecido o trânsito com anastomose jejunoileal no grupo I e jejunocecal no grupo II. Os animais foram sacrificados no 30º dia do pós-operatório para histomorfometria do cólon. Durante este período, observou-se a evolução clínica semanal, incluindo a medição do peso corporal. Resultados: Grupos I e II apresentaram perda progressiva de peso. No grupo I houve diarreia, períneo hiperemiado e cor violácea do cólon durante a autópsia. A histomorfometria mostrou hipertrofia e hiperplasia da mucosa do cólon no grupo I. No grupo II a parede do cólon estava mais espessa devido à hipertrofia e hiperplasia das camadas muscular e mucosa onde a proliferação vascular e infiltração inflamatória foi intensa. Conclusão: Este modelo é factível e atingiu 100% de sobrevida. A perda de peso não foi alterada pela presença ou exclusão da válvula ileocecal. Animais com remoção de 70% do intestino delgado e presença da válvula ileocecal apresentaram melhor evolução clínica e adaptação histológica do cólon que os sem válvula ileocecal.

Botulinum toxin as a treatment for short bowel syndrome in rats

Abstract Purpose: The denervation of the intestine with benzalkonium chloride (BAC) reduces mortality and improves weight gain in rats with short bowel syndrome (SBS). Nevertheless, translating these promising findings from bench to bedside is not feasible because BAC promotes peritonitis and irreversible denervation which may be followed by an uncontrolled dilatation of the viscera. The use of botulinum toxin (BT) instead of BAC to achieve the denervation of the remaining small intestine in SBS could be an interesting option because it leads to a mild and transient denervation of the intestine. Methods: Here we evaluated the effects of the ileal denervation with BT in rats with SBS by verifying the body weight variation and intestinal morphological parameters. Four groups with 6 animals each were submitted to enterectomy with an ileal injection of saline (group E) or BT (group EBT). Control groups were submitted to simulated surgery with an ileal injection of BT (group BT) or saline (group C - control). Results: We observed that the treatment of the remaining ileum with BT completely reversed the weight loss associated to extensive small bowel resection. Conclusion: This may provide a new promising approach to the surgical treatment of SBS.

Short bowel syndrome: treatment options / Síndrome Intestino Curto: abordagens terapêuticas

Introduction: Short bowel syndrome (SBS) refers to the malabsorptive state that occurs following extensive intestinal resection and is associated with several complications. Methods: The research for this review was conducted in the Pubmed database. Relevant scientific articles dated between 1991 and 2015 and written in Portuguese, Spanish or English were selected. Results: Several therapies, including nutritional support, pharmacological options and surgical procedures have been used in these patients. Conclusions: Over the last decades new surgical and pharmacological approaches emerged, increasing survival and quality of life (QoL) in patients with SBS. All SBS patients ought to have an individualized and multidisciplinary care that promotes intestinal rehabilitation.

Introdução: A Síndrome do Intestino Curto (SIC) resulta da perda da capacidade de absorção do intestino após resseção intestinal extensa e está associada a diversas complicações. Métodos: Esta revisão foi realizada com base em artigos científicos originais pesquisados na base de dados MEDLINE via Pubmed, na língua portuguesa, inglesa e espanhola, com o limite temporal de 1991 a 2015. Resultados: O tratamento instituído pode ser a nível nutricional, farmacológico ou cirúrgico. Conclusões: Ao longo das últimas décadas surgiram novas abordagens terapêuticas cirúrgicas e não-cirúrgicas que melhoraram a sobrevivência e a qualidade de vida (QoL) destes pacientes. Deve-se estabelecer uma abordagem multidisciplinar e individualizada para garantir a melhor reabilitação.

Insuficiencia intestinal secundaria a síndrome de intestino corto: resultados de un programa multidisciplinario de rehabilitación intestinal / Intestinal failure due to short bowel syndrome: impact of a multidisciplinary intestinal rehabilitation program

Background: In patients suffering intestinal failure due to short bowel, the goal of an Intestinal Rehabilitation Program is to optimize and tailor all aspects of clinical management, and eventually, wean patients off lifelong parenteral nutrition. Aim: To report the results of our program in patients suffering intestinal failure. Patients and Methods: A registry of all patients referred to the Intestinal Failure unit between January 2009 and December 2015 was constructed. Initial work up included prior intestinal surgery, blood tests, endoscopic and imaging studies. Also demographic data, medical and surgical management as well as clinical follow-up, were registered. Results: Data from 14 consecutive patients aged 26 to 84 years (13 women) was reviewed. Mean length of remnant small bowel was 100 cm and they were on parenteral nutrition for a median of eight months. Seven of 14 patients had short bowel secondary to mesenteric vascular events (embolism/thrombosis). Medical management and autologous reconstruction of the bowel included jejuno-colic anastomosis in six, enterorraphies in three, entero-rectal anastomosis in two, lengthening procedures in two, ileo-colic anastomosis in one and reversal Roux-Y gastric bypass in one. Thirteen of 14 patients were weaned off parenteral nutrition. Conclusions: Our Multidisciplinary Intestinal Rehabilitation Program, allowed weaning most of the studied patients off parenteral nutrition.

Outcome of pigs with short gut syndrome submitted to orthotopic intestinal transplantation

PURPOSE: To evaluate the current model of small bowel resection and intestinal transplantation in pigs. METHODS: Forty two Large White pigs were distributed in five groups: G1(n=6), G2(n=6) and G3(n=6) were submitted to 80%,100% and 100% plus right colon resection respectively and G4(n=7) and G5(n=5) to 100% SBR plus IT without and with immunosuppression based on Tacrolimus and Mycophenolic acid. Evaluation included weight control, clinical status, biochemical analysis and endoscopies for graft biopsies. Follow-up in G1 and 2 was 84 days, while in G3, four and five was ± three weeks. RESULTS: G1 increased weight suggesting adaptation while G2 and 3 loused weight and inadequate adaptation. G4 and 5 died of acute cellular rejection (ACR) and sepses respectively. Overall survival in G1, 2, 3, 4 and 5 at 30 days was 100, 100, 0 and 20 %, respectively. Medium survival in G4 and 5 was 14 and 16 days. CONCLUSIONS: The resection of 80% of small intestine in pigs is not suitable for short bowel syndrome induction. Intestinal transplantation with the proposed immunosuppression protocol was effective in prevent the occurrence of severe acute rejection, but inappropriate to increase recipients survival. .

Enteroplastía transversa seriada como alternativa en el tratamiento del síndrome de intestino corto: caso clínico / Serial transverse enteroplasty for short bowel syndrome: case report

Among patients with short bowel syndrome, surgical small intestine lengthening techniques are employed to increase the absorptive surface. Among these, serial transverse enteroplasty involves transecting the bowel transversally, preserving the blood supply of the small intestine and creating a longer segment of bowel. We report a 51-year-old woman with a short bowel syndrome and multiple hospital admissions for complications. She was subjected to a serial transverse enteroplasty, increasing small intestinal length from 140 to 180 cm. During the postoperative period, she presented intra abdominal blood collections and a septic episode with bacterial endocarditis. One month after the operation, total parenteral nutrition was discontinued and nutritional and fuid balances were achieved using exclusively the oral route. During the ambulatory follow up, the patient continues with exclusive oral feeding and fve bowel movements per day.

Primer trasplante de intestino en Chile: Caso clínico / Small bowel transplantation: Report of a single case

Small bowel transplantation is associated with a patient survival atone and five years, of 80% and 63%, respectively. We report a 36 year-old female with short bowel syndrome, subjected to the first small bowel transplantation performed in Chile. A cadaveric graft was used. Immunosuppression was achieved by means of alemtuzumab, tacrolimus, sirolimus, micofenolate mofetil and steroids. Serial endoscopies and biopsies were performed during sevenmonths after transplantation. The most important late complications were a drug induced renal failure, infections caused by opportunistic agents and a gastrointestinal bleeding probably induced by drugs. After 29 months of follow up, the patient is ambulatory, on oral diet only, and with no evidence of graft rejection.

Anastomosis colónica múltiple en el tratamiento quirúrgico del intestino corto: una nueva técnica / Multiple colonic anastomoses in the surgical treatment of short bowel syndrome: a new technique

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 [quot ]intestinal failure[quot ] 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.

Síndrome do intestino curto e transplante intestinal: modelo experimental porcino / Of short bowel syndrome and intestinal transplantation: experimental porcine model

Para melhor compreender as alterações hidro-eletrolíticas, metabólicas e nutricionais em animais de grande porte submetidos a ressecções intestinais extensas e transplante intestinal, propusemos o presente estudo no intuito de se estabelecer um modelo experimental para a Síndrome do Intestino Curto e transplantes intestinais em suínos. MÉTODO: Quarenta e dois porcos Landrace - Large White foram ressecados e divididos em cinco grupos: Grupo 1 (n igual 6) 80% ressecção intestinal; Grupo 2 (n igual 6), ressecção intestinal total; Grupo 3 (n igual 6) ressecção intestinal total e de cólon parcial incluindo válvula ileocecal; Grupo 4 (n igual 7) ressecção intestinal total e transplante intestinal sem imunossupressão e Grupo 5 (n igual 5) ressecção intestinal total e transplante intestinal com utilização de tacrolimo e micofenolato de sódio como imunossupressores. O tacrolimo foi administrado por via oral na dose de 0,2 mg/kg/dia e o micofenolato sódico na dose de 15 mg/kg/dia. O nível sérico do tacrolimo foi ajustado para 15-20 ng/ml. O tempo de acompanhamento dos grupos 1 e 2 foi de 84 dias, enquanto nos grupos 3, 4 e 5 foi de aproximadamente 3 semanas. A avaliação pós-operatória incluiu peso semanal, avaliação clinica e análise bioquímica (sódio, potássio, cálcio, glicemia, uréia, creatinina, triglicérides, colesterol total, proteínas totais, albumina e leucograma). Foi realizada endoscopia convencional com biópsia de enxerto semanal para avaliar a rejeição. RESULTADOS: Grupo 1 ganhou peso corpóreo sugerindo adaptação intestinal, os grupos 2 e 3 perderam peso mostrando inadequada adaptação à ressecção intestinal. Os porcos do grupo 4 e 5 morreram de rejeição celular aguda grave e sepse, respectivamente. Só 1 animal no grupo 5 foi à óbito por intussuscepção. A sobrevivência total em grupos 1, 2, 3, 4 e 5 no dia 30 foi 100%, 100%, 0%, 0% e 20%, respectivamente. A sobrevivência mediana no grupo 4 e 5 foi 14 e 16 dias, respectivamente...

Efeitos da desnervação intrínseca do jejuno após enterectomia extensa na síndrome do intestino curto em ratos / Effects of intrinsic denervation of the jejunum after extensive enterectomy in the rat bowel syndrome

OBJETIVO: Investigar em ratos Wistar as respostas adaptativas da mucosa em conseqüência da desnervação intrínseca do jejuno após ressecção intestinal extensa. MÉTODOS: Utilizaram-se 30 ratos distribuídos em três grupos segundo o procedimento realizado: C (controle), R (ressecção intestinal) e D (ressecção intestinal e desnervação intrínseca do jejuno). Posteriormente foi avaliado o ganho de peso e realizado estudos morfométrico da mucosa intestinal. RESULTADOS: Os animais do grupo D apresentaram ganho ponderal consideravelmente maior do que os do grupo R (D=312,2±21g e R=196,7±36,2g). A contagem neuronal mostrou diminuição na população de neurônios mientéricos no grupo D (344,8±34,8 neurônios/mm de jejuno) em relação aos outros grupos (R=909,0±55,5 e C=898,5±73,3). A área do epitélio da mucosa jejunal foi maior no grupo D (10,8±4,3mm²) em comparação aos grupos R (7,3±3,9mm²) e C (5,8±3,0mm²). O índice de proliferação celular epitelial da mucosa foi maior no grupo D (48,7 por cento), em relação aos grupos R (31,9 por cento) e C (23,6 por cento). CONCLUSÕES: O modelo experimental mostrou-se eficaz em melhorar o ganho ponderal dos animais submetidos à ressecção intestinal extensa, provocando intensificação da resposta hiperplásica da mucosa, a qual provavelmente levou a aumento da superfície de absorção de nutrientes. Abrem-se boas perspectivas para novas abordagens cirúrgicas para a síndrome do intestino curto.

Síndrome do intestino curto / Short bowel syndrome

A ausência de autonomia intestinal é grande desafio na síndrome do intestino curto. Peculiaridades no manejo clínico, nutricional e cirúrgico devem ser lembradas para a obtenção do sucesso terapêutico. As grandes ressecções intestinais dependem da adaptação do intestino remanescente e, principalmente, da utilização de suplemento nutricional e substâncias estimuladoras do trofismo da mucosa. O advento do transplante de intestino delgado veio permitir o resgate daqueles pacientes refratários a todos os tratamentos.

Short bowel syndrome (SBS) is the clinical entity that results from an effective reduction in the functioning intestinal absorptive surface, which leads to malabsorption and a inability to maintain an adequate nutritional status. This paper reviews the pathophysiology of intestinal resection, the metabolic derangements and nutritional deficits and surgical therapy.

Participação da apoptose na rejeição aguda do transplante intestinal em ratos / Apoptosis participation in the acute rejection of intestinal transplantation in rats

RACIONAL: O transplante de intestino delgado é procedimento cirúrgico em estudo visando sua aplicação no tratamento dos pacientes portadores da síndrome do intestino curto, com vistas à reabilitação oral. A grande barreira, porém, se deve à rejeição pela grande quantidade de tecido linfóide presente no intestino delgado. OBJETIVO: Estudo da apoptose em alotransplante heterotópico intestinal. MATERIAL E MÉTODOS: Realizaram-se 24 alotransplantes intestinais em ratos da raça Brown-Norway (doador) para Lewis (receptor), sendo subdivididos em três subgrupos de oito animais, sacrificados respectivamente no terceiro dia de pós-operatório (Tx(3)), no quinto dia de pós-operatório (Tx(5)) e no sétimo dia de pós-operatório (Tx(7)) para coleta das biopsias dos enxertos intestinais. Compararam-se os resultados com o grupo isotransplante (C) que envolveu oito animais da raça Lewis (doador) para Lewis (receptor), porém neste grupo realizaram-se biopsias seriadas no mesmo animal, sendo subdivididos em três momentos: biopsia no terceiro dia de pós-operatório (C(3)), no quinto dia de pós-operatório (C(5)) e sacrificados no sétimo dia de pós-operatório (C(7)) para coleta da biopsia. Realizou-se, inicialmente, análise intragrupo entre os momentos C(3), C(5) e C(7) para todos os parâmetros de rejeição citados anteriormente, como também para os três subgrupos Tx(3), Tx(5) e Tx(7). Posteriormente, realizou-se a análise intergrupo de forma transversal e pareada comparando-se o grupo isotransplante com o grupo alotransplante. (C(3) com Tx(3); C(5) com Tx(5) e C(7) com Tx(7)). No grupo isotransplante não houve expressão estatística quanto aos marcadores analisados. Porém, no grupo alotransplante observou-se que alterações da apoptose foram marcantes a partir do terceiro dia de pós-operatório.

Estudo das alterações das citocinas inflamatórias na rejeição aguda do transplante intestinal em ratos / Cytokine participation in the acute rejection of intestinal transplantation in rats

RACIONAL: O transplante de intestino delgado é procedimento cirúrgico em estudo visando sua aplicação no tratamento dos pacientes portadores da síndrome do intestino curto, com vistas à reabilitação oral. Porém a grande barreira se deve à "rejeição" pela grande quantidade de tecido linfóide presente no intestino delgado. OBJETIVO: Avaliar a atuação das citocinas, interleucina-6 e interferon-gama em alotransplante heterotópico intestinal. MATERIAL E MÉTODOS: Realizaram-se 24 alotransplantes intestinais em ratos da raça Brown-Norway (doador) para Lewis (receptor), sendo subdivididos em três subgrupos de oito animais, sacrificados respectivamente no terceiro dia de pós-operatório (Tx(3)), no quinto dia de pós-operatório (Tx(5)) e no sétimo dia de pós-operatório (Tx(7)) para coleta das biopsias dos enxertos intestinais. Enquanto que no grupo isotransplante (C) envolveu oito animais da raça Lewis (doador) para Lewis (receptor), porém neste grupo realizaram-se biopsias seriadas no mesmo animal, sendo subdivididos em três momentos: biopsia no terceiro dia de pós-operatório (C(3)), no quinto dia de pós-operatório (C(5)) e sacrificados no sétimo dia de pós-operatório (C(7)) para coleta da biopsia. Realizou-se inicialmente análise intragrupo entre os momentos C(3), C(5) e C(7) para todos os parâmetros de rejeição citados anteriormente, como também para os três subgrupos Tx(3), Tx(5) e Tx(7). Posteriormente, realizou-se a análise intergrupo de forma transversal e pareada comparando-se o grupo isotransplante com o grupo alotransplante (C(3) com Tx(3); C(5) com Tx(5) e C(7) com Tx(7)). RESULTADOS: No grupo isotransplante não houve diferença estatisticamente significante quanto à imunoexpressão das citocinas estudadas, todavia no grupo alotransplante observou-se que alterações da interleucina-6 e de interferon-gama ocorreram a partir do quinto dia de pós-operatório.

Study of morbidity in orthotopic small intestine transplantation with wistar rats: experimental study

Transplantation of the small intestine is a surgical procedure currently under investigation for its possible application in the treatment of patients with short bowel syndrome, aiming at the reintroduction of an oral diet. AIM: To define the morbidity and mortality of intestinal transplantation in small animals using microsurgery. Intra and postoperative morbidity and mortality were studied in Wistar rats submitted to orthotopic intestinal allotransplantation. MATERIAL AND METHOD: The animals were divided into three groups: group A (37 donor animals), group B (37 recipient animals), and group C (10 control animals). Group B was divided into three subgroups according to survival time. Subgroup TI consisted of animals that died during surgery or due to causes directly related to surgical intervention, subgroup T2 consisted of animals that died between the 4th and 29th postoperative day, and subgroup T3 consisted of animals that survived after 30 days. Transplanted animals were evaluated in terms of surgical technique used (vascular and intestinal anastomosis), graft quality, surgical time, and clinical parameters. The animals that died by the 29th postoperative day were submitted to autopsy and the remaining ones were sacrificed after 30 days. RESULT: There was a high rate of complication of a surgical nature. Early mortality rate, i.e., mortality up to the third postoperative day, was 54% with vascular anastomosis being the major cause of death. Surgical time was evaluated in a restricted and homogeneous group and showed a strong prognostic value in terms of successful transplantation. Clinical parameters such as weight loss, reduction of ingestion, reduction of motor activity and diarrhea were directly correlated with acute rejection. CONCLUSION: The experimented intestinal transplant is a procedure companied by considerable morbidity and mortality due to surgical complications in postoperative period, vascular anastomosis and total surgical time

Intestinal intussusception and occlusion caused by small bowel polyps in the Peutz-Jeghers syndrome. Management by combined intraoperative enteroscopy and resection through minimal enterostomy: case report

The Peutz-Jeghers syndrome is a hereditary disease that requires frequent endoscopic and surgical intervention, leading to secondary complications such as short bowel syndrome. CASE REPORT: This paper reports on a 15-year-old male patient with a family history of the disease, who underwent surgery for treatment of an intestinal occlusion due to a small intestine intussusception. DISCUSSION: An intra-operative fiberscopic procedure was included for the detection and treatment of numerous polyps distributed along the small intestine. Enterotomy was performed to treat only the larger polyps, therefore limiting the intestinal resection to smaller segments. The postoperative follow-up was uneventful. CONCLUSION: We point out the importance of conservative treatment for patients with this syndrome, especially those who will undergo repeated surgical interventions because of clinical manifestation while they are still young

Oxygen consumption of rats with broad intestinal resection

The study was performed to investigate possible alterations in oxygen consumption in an animal model with broad intestinal resection. Oxygen consumption and the thermal effect of a short meal were measured in rats subjected to short bowel syndrome. Four groups of rats were used. Group I was the control group, group II was sham operated, group III was submitted to 80 percent jejunum-ileum resection, and group IV was submitted to 80 percent jejunum-ileum resection with colon interposition. Ninety days after surgery, oxygen consumption was measured over a period of 6 h with the animals fasted overnight. The thermal effect of feeding was determined in another session of oxygen consumption measurement in animals fasted for 12 h. A 12-kcal meal was then introduced into the animal chamber and oxygen consumption was measured for a further 4 h. No differences in fasting oxygen consumption or in the thermal effect of the meal were detected among the groups studied. It is concluded that short bowel syndrome does not affect the overall energy expenditure of rats

Manejo anestésico del transplante intestinal: Reporte de un caso / Anesthetic management for bowel transplantation. Case report

Antecedentes: El Síndrome de Intestino Corto (SIC) se caracteriza por diarrea, pérdida de peso y desnutrición en pacientes que sufren de algún trastorno en la motilidad o absorción intestinal o en aquellos que por diversas causas se les ha resecado más del 50 por ciento de la longitud intestinal total y que requieren de apoyo nutricio parenteral más allá de 3 meses. Hasta 1997 se habían reportado 273 casos de trasplante intestinal en el mundo, el presente reporte está relacionado con el segundo en nuestro país y el primero realizado de donador vivo relacionado. Caso clínico: Paciente masculino de 21 años de edad con SIC secundario a lesión por proyectil de arma de fuego que condicionó resección intestinal, con una longitud residual total de 10cm de intestino delgado y 55cm de colon. Se inició la preparación para trasplante intestinal con injerto de su hermana con quien compartía 3 antígenos HLA y grupo sanguíneo. Se monitorizó al paciente en forma invasiva y no invasiva. La anestesia se administró con Citrato de Fentanyl e Isoflurano en 02 al 100 por ciento. Se tomaron registros de ph, electrolitos, pruebas de coagulación, hemoglobina, hematocrito y plaquetas durante un tiempo quirúrgico y anestésico de 19 y 20 horas respectivamente. Se manejo la terapia inmunosupresora desde el período pre, trans y postanestésico. La ecolución postoperatoria inicial fue satisfactoria hasta el séptimo día en que presentó datos de lesión pulmonar aguda y muerte. Conclusión: Aunque el programa de trasplante intestinal está iniciando, ofrece una alternativa de manejo para pacientes con síndrome de intestino corto.

Anestesia en trasplante de intestino delgado: informe del primer caso en Argentina / Anesthesia in small bowel transplantation: first case report in Argentine

Antecedentes: El trasplante de intestino delgado es un complejo procedimiento que se practica a adultos o niños que, por distintas causas, sufren una amplia resección de ese órgano. Esta intervención puede ser el tratamiento definitivo para los enfermos con síndrome de malaabsorción, que se encuentran obligados a recibir alimentación parenteral el resto de su vida, con graves efectos colaterales. Objetivos: Describir la conducta anestésica empleada en el primer caso de trasplante de intestino delgado en nuestro país. Lugar de aplicación: Hospital Italiano de Buenos Aires. Diseño: Estudio descriptivo. Población: Niño de 6 años, con síndrome de intestino corto desde los 6 meses por enteritis necrotizante. Recibió alimentación parenteral durante 5 años y medio, por lo que desarrolló insuficiencia hepática de grado leve con alteraciones de la coagulación. Método: Técnica anestésica: premedicación con midazolam 0.1 mg/kg y fentanilo 1.5 µg/kg. Mantenimiento: remifentanilo 1 µg/kg/min y oxígeno/aire en mezcla con isofluorano. Monitoreo : presión arterial invasiva, presión de la arteria pulmonar y de enclavamiento, oximetría y capnografía, ECG, temperatura central, diuresis, estado ácido-base, hematocrito y hemoglobina, ácido láctico, calcio iónico, glucemia, control de la coagulación, monitoreo neuromuscular, consumo y disponibilidad de oxígeno y saturación venosa mixta de oxígeno. Hidratación intraoperatoria: infusión continua de albúmina. Se mantuvo la estabilidad hemodinámica con fenilefrina (0.5 µg/kg/min) y dopamina (5µg/kg/min.). Para la corrección de las alteraciones de la coagulación fue necesario utilizar hemoderivados. El uso de fenilefrina disminuyó la exigencia de excesiva hidratación intraoperatoria. Resultados: Se alcanzaron los objetivos propuestos: prevenir el edema de la pared intestinal, evitar un grave síndrome de reperfusión, disminuir el estrés quirúrgico y anticipar las posibles complicaciones intraoperatorias. Los valores registrados de ácido láctico fueron elevados (6.2 milimoles/litro), probablemente debidos a la nutrición parenteral crónica. Conclusiones: La conducta anestésica utilizada ha conservado una adecuada estabilidad hemodinámica, además de optimizar el estado de la coagulación, mantener la temperatura central y equilibrar el estado ácido-base.