Q: What are the treatment components of intestinal rehabilitation?

1. Diet Modification: First Line Therapy 2. Oral Rehydration Therapy 3. Vitamin and Mineral Supplements 4. Pharmacological Therapy • Anti-Diarrheal agents to slow transit time and increase absorption. • Proton-pump inhibitors to decrease gastric hypersecretion. • Probiotics or antibiotics to treat small bowel bacterial overgrowth. • Exogenous bile salts to help with fat and calcium absorption. • Teduglutide (GLP2) recombinant human glucagon-like peptide 2. • Surgical Interventions, including autologous reconstruction and bowel lengthening techniques such as the Bianchi and Serial Transverse Enteroplasty (STEP) procedures. Refer to reference (3) below for more information.

Q: What are the medical contraindications to intestinal transplant?

• Marked cardiopulmonary deficiency. • Aggressive malignancy. • Advanced autoimmune disease. • Acquired immunodeficiency syndrome (AIDS). • Existence of life threatening intra-abdominal infections or sepsis.

Q: What are the psychosocial contraindications to intestinal transplant?

• Addiction/alcoholism • Poor or absent support system to help after transplant, or • Mental health issues for which the patient refuses treatment which may affect survival.

Question 1

What characterizies the intestinal adaptive response post-resection?

Accepted Answer

The intestinal adaptive response is characterized by: (after major intestinal resection)
 
 • Structural changes: Increased crypt cell proliferation which results in deeper crypts and increased villus height. Angiogenesis also occurs. 
 • Functional changes: Increased absorptive function, slower transit time, and accelerated cell differentiation. 
 
Refer to (1).

Question 2

What are predictive factors for a successful intestinal rehabilitation?

Accepted Answer

1. Length and status of remaining bowel.
2. Distal versus proximal resection. 
3. Patient age.
4. Presence of ileocecal valve or colon.
5. Status af abdominal visceral vascular structure. 
 
Refer to reference (2) listed in citations below for more information.

Question 3

What is intestinal rehabilitation?

Accepted Answer

Prior to pursuing transplant, intestinal rehabilitation is usually attempted in patients with intestinal failure.
 
Intestinal rehabilitation is the process of restoring nutritional autonomy in patients with intestinal failure to enteral feeding with the goal of weaning the patient from parenteral nutrition (PN). 
 
Refer to (2).

Question 4

What are the treatment components of intestinal rehabilitation?

Accepted Answer

1. Diet Modification: First Line Therapy
​
2. Oral Rehydration Therapy
 
3. Vitamin and Mineral Supplements
​
4. Pharmacological Therapy
 
 • Anti-Diarrheal agents to slow transit time and increase absorption.
 • Proton-pump inhibitors to decrease gastric hypersecretion.
 • Probiotics or antibiotics to treat small bowel bacterial overgrowth.
 • Exogenous bile salts to help with fat and calcium absorption.
 • Teduglutide (GLP2) recombinant human glucagon-like peptide 2.
 • Surgical Interventions,  including autologous reconstruction and bowel lengthening techniques such as the Bianchi and Serial Transverse Enteroplasty (STEP) procedures.
 
Refer to reference (3) below for more information.

Question 5

What is glucagon-like peptide 2 (GLP-2)?

Accepted Answer

• Intestine specific 33 amino acid peptide product of the post-translational processing of proglucagon.
 • Produced by the L cells in the ileum and colon.
 • Produced when there are luminal nutrients in the ileum and/or colon.
 • Enhances small and large intestinal villus and crypt cell growth.
 • Helps to maintain mucosal integrity.
 • Helps to increase nutrient absorption.
 • Teduglutide, a GLP-2 analog, has recently been approved as an agent to use in patients with short bowel syndrome to improve intestinal absorption. 
 • Currently there are similar analog compounds in the clinical trial phases of development for short bowel patients, including a GLP-2 analog called apraglutide. 
 
Please refer to (6) for more information.

Question 6

What is the Bianchi procedure?

Accepted Answer

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. 
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. 
Refer to (2,7).

Question 7

What is the Serial Transverse Enteroplasty Procedure (STEP)?

Accepted Answer

The Serial Transverse Enteroplasty Procedure (STEP) 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. 
The STEP procedure has been shown to increase bowel length, reduce dependence on PN, improve patient growth, improve intestinal motility, and helps to avoid intestinal transplant. 
Refer to (2,7).

Question 8

What are the Centers for Medicare and Medicaid (CMS) approved indications for intestinal transplant?

Accepted Answer

Failure of Parenteral Nutrition
 • Impending (total bilirubin 3-6 mg/dL, progressive thrombocytopenia, and progressive splenomegaly) or overt liver failure (portal hypertension, hepatosplenomegaly, hepatic fibrosis, or cirrhosis) because of parenteral-nutrition-liver injury.
 • Central venous catheter-related thrombosis of 2 central veins.
 • Frequent central line sepsis: 2 episodes/year systemic sepsis secondary to line infections requiring hospitalization; a single episode of line related fungemia; septic shock or acute respiratory distress syndrome.
 • Frequent episodes of severe dehydration despite IV fluid in addition to parenteral nutrition.
High Risk of Death Attributable to Underlying Disease
 • Desmoid tumors associated with familial adenomatous polyposis.
 • Congenital mucosal disorders (e.g. microvillus atrophy and intestinal epithelial dysplasia).
 • Ultra-short bowel syndrome (gastrostomy, duodenostomy, residual bowel <10 cm in infants and <40 cm in adults).
Intestinal Failure with High Mortality or Low Acceptance of Parenteral Nutrition
 • Intestinal failure with high morbidity (frequent hospitalizations; narcotic dependency) or inability to function (e.g. pseudo obstruction, high output stoma).
 • Patient’s unwillingness to accept long term parenteral nutrition (e.g. pediatric patients).
Please refer to (6) for more information.

Question 9

What are the medical contraindications to intestinal transplant?

Accepted Answer

• Marked cardiopulmonary deficiency.
 • Aggressive malignancy.
 • Advanced autoimmune disease.
 • Acquired immunodeficiency syndrome (AIDS).
 • Existence of life threatening intra-abdominal infections or sepsis.

Question 10

What are the psychosocial contraindications to intestinal transplant?

Accepted Answer

• Addiction/alcoholism
 • Poor or absent support system to help after transplant, or
 • Mental health issues for which the patient refuses treatment which may affect survival.

Intestinal Rehabilitation and Indications for Intestinal Transplant