SAN DIEGO – Treating gut failure after bariatric surgery involves meeting patients’ nutritional needs while avoiding a recurrence of morbid obesity, according to Dr. Kareem Abu-Elmagd of the Cleveland Clinic.
Surgeons must be flexible, and should be familiar with a variety of reconstructive techniques to restore patients to nutritional autonomy while minimizing the need for visceral transplantation, he said.
Gut failure is a rare but serious and potentially life-threatening complication of bariatric surgery. When it occurs, the patient can no longer meet nutritional needs autonomously, but rather requires total parenteral nutrition (TPN). Although comprehensive medical management including TPN is necessary when gut failure occurs, reconstructive surgery or visceral transplantation is the only means to allow patients to regain nutritional autonomy.
Dr. Abu-Elmagd reported the results of 2 decades of experience with post–bariatric surgery gut failure at the Cleveland Clinic and the University of Pittsburgh Medical Center at the annual meeting of the American Surgical Association. He and his coinvestigators at the two facilities assessed a total of 131 patients who were referred for gut failure from 1995 to 2015. The number of referrals, said Dr. Abu-Elmagd, has been increasing sharply, with nearly two-thirds of patients referred over the past 5 years.
The study sought to identify the types and causes of gut failures seen, to describe surgical techniques used for repair or transplant, and to track outcomes for patients after surgical repair for gut failure. Of the 131 patients in the study, 100 had a Roux-en-Y or similar combined malabsorptive and restrictive surgery as their primary bariatric procedure. Overall, 85% of patients were female.
Dr. Abu-Elmagd classified gut failure into three major groups: 55 patients (42%) had type I or catastrophic gut loss, which included strangulation and vascular occlusion; 43 patients (33%) had type II gut failure, caused by technical complications such as loss of gut continuity, strictures, and fistulae; and 33 patients (25%) had type III gut failure, caused by dysfunctional syndromes such as dysmotility, restriction, or absorption.
Of the 131 patients referred, 116 went on to have a total of 317 restorative procedures. Most (n = 84, 72%) needed reversal of their primary bariatric procedure. Patients received a total of 198 autologous reconstruction procedures, while 10 intestinal-lengthening procedures and 25 visceral transplantations were performed.
Dr. Abu-Elmagd and his colleagues characterized the reconstruction procedures according to the embryonic origins of the structures repaired. Seventy-eight patients had major reconstruction of the foregut, “the most tedious and technically challenging procedure … to restore normal gut anatomy and physiology,” said Dr. Abu-Elmagd. Three other patients had gastroplasty to restore the foregut, and seven needed to have an alimentary conduit interposed in order to restore normal alimentary flow. Mid- and hindgut reconstructions (n = 110) were essential to maximize absorption and restore nutritional autonomy, he said.
If patients had less than 100 cm of small bowel remaining, they received serial transverse enteroplasty, an intestinal-lengthening procedure. The few patients who needed intestinal, liver-intestine, or multivisceral transplantations had ultrashort gut syndrome and could not be maintained on TPN.
Five-year cumulative survival for those receiving reconstruction or transplantation was 84%, and plateaued at 72% at 10 and 15 years post restoration. For the subset who received transplantation, the 5-year survival was 69%. Among the first 100 surviving surgical patients, 83% retained full nutritional autonomy.
Bariatric surgery, noted discussant Dr. Debra Sudan of Duke University, “is clearly the most effective treatment for obesity and has tremendous impact on comorbidities,” but, since it is an elective procedure, “it’s devastating when complications develop.” She asked what considerations were specific to the bariatric population when dealing with gut failure.
Bariatric patients, said Dr. Abu-Elmegd, have the advantage that they do not have an underlying disease process, and overall they have the ability to adapt and return to more normal gut function very quickly. From a surgical perspective, the solutions must be flexible and tailored to the patient. He said, “Whatever the patient has, you fix it.”
The authors reported no relevant financial disclosures.