Editing Short bowel syndrome (section)

== '''Late phase management''' ==

* Medical
** TPN/fluids/micronutrients as required at steady state
*** B12
*** Fat-soluble vitamins
*** Calcium, magnesium, zinc, selenium
** Teduglutide (GLP-2 analogue) - if unable to wean from TPN despite aggressive therapy - initiates and maintains small bowel adaptive response to resection and improves nutrient absorption
** Prevent and treat bone disease and other complications
* Surgical strategies - limited success
** Preserve existing bowel length and restore continuity
** Delay intestinal transit time
*** Construction of various valves and sphincters
*** Anti-peristaltic segments - moderate success
*** Abandoned techniques:
**** Colonic interposition
**** Recirculating loops of bowel
**** Retrograde electrical pacing
** Increase absorptive area
*** Bianchi procedure - intestinal tapering and lengthening procedure - serial transverse enteroplasty - possibly gets good results in well-selected patients- 90% show improved nutrition, and can lengthen by up to 55% in some patients - but high-risk of complications. Need a distended gut for this to work, which is not commonly seen in adults. Increase length but more importantly slow transit. Starkey has never seen it. 
** Intestinal transplantation
*** Standard of care for patients in whom intestinal rehabilitation has failed and are at risk of life-threatening TPN complications (impending liver failure, thrombosis of more than two major access veins, frequent severe line infections, dehydration)
*** One year survival of 77%; 5 year survival 58%, even in modern times. Lots of perioperative mortality but then ongoing attrition.
*** Can be done in combination with liver - 5 year survival 54%
*** No role for transplantation in the acute setting - wait for extent of disease to become clear
*** Recognised by USA medicare system in 2000 - progressive uptake since then. Most of the initial indications were related to complications of home TPN, 'failure of TPN', see above.
*** There are about 5000 people worldwide, as of June 2023, who have had a transplant at a recognised centre, based on registrary data, and only 100-200 per year nowadays. 13 Australians transplanted as of June 2023.