Exploring the Benefits of Early Lengthening in SBS in Children in Faster Bowel Rehabilitation

Introduction: To compare the effects of early bowel lengthening in short bowel syndrome (SBS) on bowel rehabilitation reported in the literature to our centre experience. Methods: We performed in OVID MEDLINE/EMBASE search for all pediatric bowel lengthening cases in the last 35 years and retrospectively reviewed all cases underwent bowel lengthening at our center. Early lengthening was defined as any bowel lengthening procedure performed before 6 months of age. Results: 27 papers reported over 65 early bowel lengthening procedures. Median age at surgery 45 days [IQR 12-101]. The most frequent diagnosis was small bowel atresia followed by gastroschisis. Longitudinal intestinal lengthening and tailoring (LILT) and serial transverse enteroplasty procedure (STEP) all featured almost equally as the methods of choice. Failure of enteral nutrition was the mainstay indication for early lengthening at the outset. However, the indication, type and timing of early lengthening procedure has dramatically shifted over the last 5 years towards neonatal STEP (Fig.1). In the First STEP group (n= 22) following a median follow up of 24 months [IQR 16-26] 60% required a second STEP, 40% are still PN dependant, 3 more cases achieved enteral autonomy following a second STEP, 2 infants died and one required small bowel transplantation. Over the last 10 years we performed bowel lengthening on 35 cases of SBS. In the early lengthening group (n= 9), gastroschisis was the dominant diagnosis (65%), median age at surgery 121 days [IQR 102–140] and pre-operative small bowel (SB) length 30cm [IQR 20–49]. STEP and LILT were equally performed and re-dilatation following primary anastomosis or failure of enteral nutrition were the only indications for early lengthening. At a median follow up of 67 months [IQR 45–90] half of the cases achieved full enteral autonomy, whilst the remaining cases require partial parenteral nutrition supplementation. Conclusion: More recently, clear recognition of uncertainty on timing and indications for early lengthening in SBS in children is lacking in the literature. We believe that early lengthening for tailoring and tapering purpose in full term neonates with SBS may have a role in restoring bowel physiology. There are no clear benefits in the literature from early lengthening in achieving faster bowel rehabilitation or prevention from further surgical intervention.