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Reply to Letter to the Editor on European Pediatric Surgeon' Association Survey on the Management of Short Bowel Syndrome
We greatly appreciate Dr. Morabito A and his colleagues' interest in reading our work and commenting on it. We hope this reply to the main concerns and comments may be helpful.
This survey principally assessed the management of short bowel syndrome (SBS) at the time of the primary surgical procedure of several rare but typical underlying lesions leading to SBS. It finally concluded that knowledge about SBS should not only be restricted to multidisciplinary Intestinal Rehabilitation Program teams but also be included in medical educational programs for all pediatric surgeons who will have to experience primary surgical procedures leading to SBS.
Regarding complete midgut volvulus with extensive necrotic bowel, we agree that leaving nonviable bowel by reducing the volvulus with no bowel resection followed by a second-look may be an additional life-threatening factor in frail neonates. The surgical strategy needs to be discussed for each individual neonate regarding his/her long-term future intestinal prognosis and the risks of developing severe complications related to SBS, particularly intestinal failure–associated liver disease. In the most severe cases, a complete resection of the entire bowel (that may include the ileo-cecal valve) resulting in a duodenostomy should be greatly considered from an ethical point of view. However, the potential of intestinal recovery from severe ischemia needs to be assessed during this primary surgery to decide if a large resection of the most necrotic dead bowel may increase the survival with an acceptable long-term intestinal prognosis. However, complete midgut volvulus must be differentiated from large segmental volvulus for which the surgical strategy is truly different, with a more limited length of intestinal loss that is also associated with significant postnatal morbidity.
In multiple intestinal atresia, we agree that the resection of the smallest atretic segments of bowel to perform two to three anastomoses to avoid multiple postoperative stenosis, which may lead to recurrent surgeries and worsen the intestinal prognosis, is probably the most reasonable surgical approach. However, Hatch and Schaller developed a very smart surgical strategy using a transluminal stent to preserve all the viable segments of bowel regardless of their length. This surgical strategy needs to be considered as an additional tool for pediatric surgeons to improve the long-term intestinal prognosis of neonates, but the main technical principles need to be well understood. First, a smooth transluminal catheter adapted to the diameter of the bowel is threaded through all segments of the viable bowel. Second, three to four tacking stitches are placed just to keep the pieces approximated. A formal intestinal anastomosis should not be performed to avoid multiple postoperative stenosis. The surgical technique was well described by Romão et al.
Therefore, the main concern of all pediatric surgeons who confront these rare underlying neonatal conditions leading to SBS should be “how to be prepared” to face them to offer the patient the best long-term intestinal prognosis.
Received: 30 May 2021
Accepted: 15 June 2021
26 July 2021 (online)
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- 1 Dariel A, Faure A, Martinez L. et al. European Pediatric Surgeon' Association Survey on the Management of Short-Bowel Syndrome. Eur J Pediatr Surg 2021; 31 (01) 8-13
- 2 Khen-Dunlop N, Beaudoin S, Marion B. et al. Segmental volvulus in the neonate: a particular clinical entity. J Pediatr Surg 2017; 52 (03) 454-457
- 3 Hatch EI, Schaller RT. Surgical management of multiple intestinal atresias. Am J Surg 1986; 151: 550-552 DOI: 10.1016/0002-9610(86)90541-6.
- 4 Romão RLP, Ozgediz D, de Silva N, Chiu P, Langer J, Wales PW. Preserving bowel length with a transluminal stent in neonates with multiple intestinal anastomoses: a case series and review of the literature. J Pediatr Surg 2011; 46 (07) 1368-1372