Autologous Reconstruction of the Gastrointestinal Tract: An Alternative to Intestinal Transplant

Although intestinal transplant has come a long way with the introduction of new immunosuppression protocols, it is still in a patient’s best interest to attempt gut rehabilitation and use of his or her own intestine prior to resorting to transplantation. Techniques in autologous intestinal reconstruction have advanced in recent years, with the procedures being performed more commonly in many intestinal rehabilitation centers around the country.


The two most common procedures performed are the intestinal lengthening procedures: the Bianchi procedure and the STEP procedure.


Bianchi Procedure

This is also known as the longitudinal intestinal lengthening and tailoring (LILT) procedure, described by Bianchi in 1980. The procedure involves dividing the small bowel longitudinally using a surgical stapler (or hand sewn), and subsequently anastomosing the two sections together in an isoperistaltic fashion. This allows for the luminal contents to increase contact time with the absorptive mucosa via increasing length as well as improving peristalsis by decreasing the diameter of the bowel. (1) Limitations of the procedure include: its technical difficulty, places the mesenteric blood supply in jeopardy, and it cannot be performed again if the first procedure is unsuccessful. (2)


Serial Transverse Enteroplasty Procedure (STEP)

The STEP procedure was first performed in 2002 by surgeons at Boston Children’s Hospital. The first operation on a human was performed in 2003 and since has been utilized in many centers.3 The procedure involves lengthening dilated small bowel by creating a row of alternating slits in the small intestine and stapling the V-shaped cuts shut, creating a zig-zag like tube. The benefit of the STEP is that it has the ability to nearly double the length of the bowel, greatly enhancing the amount of time nutrients spend in contact with the absorptive intestinal surface. (1) The STEP procedure has been shown to increase bowel length, reduce dependence on TPN, improve patient growth, improve intestinal motility, and avoid intestinal transplant. (2)  About half of patients who undergo the STEP procedure are able to wean from TPN. (3)


Both techniques are viable options to consider in short bowel patients prior to resorting to intestinal transplant.



References:

  1. Sommovilla J, Warner BW. Surgical options to enhance intestinal function in patients with short bowel syndrome. Curr Opin Pediatr. 2014;26(3):350‐355. doi:10.1097/MOP.0000000000000103

  2. Serial Transverse Enteroplasty (STEP) for Patients with Short Bowel Syndrome (SBS).; 2010.

  3. Serial Transverse Enteroplasty Procedure (STEP): Boston Children's Hospital. Boston Childrens Hospital. http://www.childrenshospital.org/conditions-and-treatments/treatments/step-procedure. Accessed May 6, 2020.