Letters to the Editor
To the Editor: Few readers are likely to disagree with the main conclusions drawn by Khalil et al (1) that “with a multidisciplinary approach, combining both medical and surgical expertise, patients with short bowel syndrome can achieve enteral autonomy,” and “patients with short bowel syndrome should be treated in specialist units.” Their claim of improved outcomes, with 78% of patients achieving enteral autonomy, also may be true given the previously reported 45% survival (2); however, crucial unanswered questions include “what are the indications for longitudinal intestinal lengthening?” (can it be justified, for example, in the patient cited with 140 cm of small bowel presurgery?) and “does the initial ‘bowel expansion’ described actually produce an increase in absorptive surface area over and above that known to occur as part of the adaptive process?” (3).
The widely recognised immense heterogeneity of patients with short bowel syndrome (eg, gut length, type of gut remaining, presence of an ileocaecal valve, gut dilatation/dysmotility, primary pathology, small numbers, different surgeons) is one set of reasons why these patients will never be studied in randomised trials. The other important confounding variable, and one that is key in the context of the article by Khalil et al, is the natural history of short bowel syndrome, which is one of the spontaneous improvement in gut function on the basis of intestinal adaptation. Consequently, the majority of patients with short bowel syndrome will come off parenteral nutrition and will not need any reconstructive surgery. Against this background, it becomes extremely difficult to assess with confidence whether a reconstructive surgical intervention has helped; most patients are getting better anyway.
One reasonable way around this problem is to carry out before-and-after studies of feed tolerance, with surgery taking place at a time when each patient's adaptive process has clearly come to an end. This can be judged by an inability to advance enteral feeds of any description without producing intolerance as diarrhoea and/or vomiting, notwithstanding intensive medical and dietetic input often involving the use of modular feeds. The publication by Khalil et al (1) is notably devoid of relevant details in these respects, and the absence of a gastroenterologist among the authors is surprising given their endorsement of multidisciplinary management.
Such before-and-after studies clearly lack the rigour of a randomised trial but have been useful in providing some evidence of the effectiveness of interventions in this patient group (4,5). Unfortunately, this publication, in common with all those from the same group, fails to provide even this degree of evidence of effectiveness and cannot be considered as being supportive of the uncritical widespread use of reconstructive surgery, even in specialist centres. A retrospective case note review describing how one team manages a particular clinical problem may, even in these days of evidence-based medicine, hold some interest and stimulate discussion, but the study as it stands simply cannot answer such questions as “is one approach better than another?” or serve as the basis for a change in service provision.
1. Khalil BA, Ba’ath ME, Aziz A, et al. Intestinal rehabilitation and bowel reconstructive surgery: improved outcomes in children with short bowel syndrome. J Pediatr Gastroenterol Nutr
2. Bianchi A. Experience with longitudinal lengthening and tailoring. Eur J Pediatr Surg
3. Weale AR, Edwards AG, Bailey M, et al. Intestinal adaptation after massive intestinal resection. Postgrad Med J
4. Duggan C, Piper H, Javid PJ, et al. Growth and nutritional status in infants with short-bowel syndrome after the serial transverse enteroplasty procedure. Clin Gastroenterol Hepatol
5. Simkiss D, Adams I, Myrdal U, et al. Erythromycin in severe post-operative intestinal dysmotility in the neonate. Arch Dis Child