Integrative surgical management may benefit patients with gut failure

By Will Boggs MD

NEW YORK (Reuters Health) - 4/9/2019

Integrative surgical management, including transplantation where appropriate, may benefit people with gut failure, according to one center's experience with 500 patients.

"The most interesting observation in the study is the high probability of restoring nutritional autonomy and discontinuation of total parenteral nutrition (TPN) without the need for gut transplantation," said Dr. Kareem M. Abu-Elmagd of the Cleveland Clinic Foundation, in Ohio.

"Equally important is the cost-effectiveness and improved quality of life after surgical autologous reconstruction utilizing the residual native gastrointestinal organs," he told Reuters Health by email.

The 500 patients in the report all had TPN-dependent catastrophic and chronic gut failure and had been referred for surgical intervention, particularly transplantation, to Cleveland Clinic's Center for Gut Rehabilitation and Transplantation.

The surgical algorithm for management of these patients first divided them into those with liver failure, who underwent liver-contained gut transplant, and those without reconstructable gut with residual function, who underwent liver-free gut transplant.

Patients without liver failure but with reconstructable gut with residual function proceeded to autologous gut reconstruction (AGR) including bowel lengthening. If that did not restore nutritional autonomy, patients proceeded to redo bowel lengthening and treatment with enterocyte growth factors. If the redo procedure did not restore nutritional autonomy either, patients underwent liver-free gut transplant.

Among the 462 patients who received surgical treatment, 82% had definitive AGR, 9% underwent primary transplant and another 9% had AGR followed by transplant, the authors report in the Annals of Surgery, online August 20.

During a mean follow-up of 30 months, 112 patients died, for a mortality rate of 22%, mostly as a result of TPN-associated complications, malignancy, and surgical failure after AGR or sepsis, allograft rejection, graft-versus-host disease, and technical complications after transplant.

Restored nutritional autonomy (RNA) was documented in 69% (267/388) of survivors, including 71% of AGR patients, 83% of transplant patients, and 8% of medically managed patients. Moreover, 22% (25/112) of non-survivors were free of TPN before death.

The overall cumulative RNA rates were 49% at three months, 63% at one year, and 78% at five years, with significantly better five-year RNA rates after surgical treatment (82%) than after medical management (12%).

Of the 264 TPN-free surgical survivors, 73% resumed normal activities with no to minimal restrictions and the remaining 27% (except two transplant recipients) were able to care for themselves with occasional requirement for assistance.

The mean cost per case was $69,382 for AGR and $297,010 for transplant ($175,000 for liver-free and $325,000 for liver-contained transplant), compared with reported average charges of $250,000 annually for TPN.

"I would hope that the primary-care physicians, nutritionists, and gastroenterologists seek early consultation for the management of patients with gut failure who are not expected to wean off home parenteral nutrition within three months," Dr. Abu-Elmagd said. "Equally important is the prompt referral of the hospital-bound patients by the intensivist and general/colorectal surgeons after complex abdominal surgery or catastrophic abdominal events."

He also hopes "that this evidence-based report is utilized to establish a national policy that is adopted by healthcare providers and payers with universal guidelines for referral and clinical management."

"Because of the complexity and chronicity of most patients with chronic gut failure, this unique population must be managed at tertiary centers by a multidisciplinary team," Dr. Abu-Elmagd said. "These tertiary centers should be capable of providing state of the art nutritional, medical, and surgical management, including innovative surgical techniques, enterocyte growth factors, and gut transplantation. Early referral must be considered to further improve outcome including survival and value of healthcare."

Dr. Thomas M. Fishbein, executive director of MedStar Georgetown Transplant Institute, in Washington, D.C., told Reuters Health by email, "We still see patients with total gut loss or ischemia put on morphine drips and no option of resection and referral being offered. Such patients no longer belong in the hands of isolated surgeons or parenteral nutrition providers."

Instead, he said, these patients require "a. early identification of gut failure, b. provision of supportive care in the short run to control sepsis, fistulas, remove ischemic intestine, and leading to patient stabilization, and c. early transfer to centers equipped to manage such patients. These increasingly occur in centers experienced in both reconstructive surgery and intestinal transplants in the United States."

"Both AGR and transplant are cost-effective," said Dr. Fishbein, who was not involved in the new report. "There are still states that do not offer coverage of these care pathways or procedures under CMS funding (Medicaid and Medicare), and this should end."


Ann Surg 2019.

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