Comment on “European Pediatric Surgeon' Association Survey on the Management of Short-Bowel Syndrome”

We read with interest the article by Dariel et al “European Pediatric Surgeon' Association survey on the management of short-bowel syndrome” recently published in the journal.[1] Based on our pediatric surgical experience previously in Manchester (UK)[2] and ongoing in Florence (Italy)[3] which has been double-checked by an external reviewer/author (A.L.), we would like to provide comments on the article ([Table 1]). Regarding institutional practices, Manchester and Florence are high-volume centers with an Intestinal Rehabilitation Program but no transplant surgeon. As with most of the European centers, we use surgical strategies (>3 procedures/year in Manchester and 3 procedures/year in Florence) to facilitate enteral autonomy, promoting intestinal adaptation through an early stoma closure.

Table 1 Comparison of data between European Pediatric Surgeons' Association and Manchester/Florence

	European Pediatric Surgeons' Association	Manchester	Florence
	65 European centers (data up to 2019)	101 patients (1982–2017)	26 patients (2018–2021)
Institutional practices	Majority of centers
Number of new pediatric patients with short bowel syndrome treated per year	1–2	>5	>5
Members of the multidisciplinary Intestinal Rehabilitation Program	No transplant surgeon	No transplant surgeon	No transplant surgeon
Accredited program for teaching home parenteral nutrition to parents	No	Yes	Yes
Primary surgical management of underlying disease leading to short bowel syndrome	Majority of centers
Complete midgut volvulus with extensive necrotic bowel	No resection followed by second look	Limited resection	Complete resection
Multiple intestinal atresia	Preserve all segments	Resect segments to perform 2–3 anastomoses	Resect segments to perform 2–3 anastomoses
Ultra-short bowel due to proximal jejunal atresia	Jejunostomy followed by anastomosis to colonic remnant	Jejunostomy followed by anastomosis to colonic remnant	Primary anastomosis to colonic remnant
Strategies to facilitate enteral autonomy	Majority of centers
Frequency of surgical lengthening procedures	2–3/y	>3/y	3/y
Procedures of choice for small bowel dilatation (complicated with bacterial overgrowth and dysmotility)	Step	Bianchi	Step
Strategies to promote intestinal adaptation	Early stoma closure	Early stoma closure	Early stoma closure

We do sometimes alter our primary surgical management, dependent on the underlying disease leading to short bowel syndrome: in keeping with most European centers, in Manchester, we performed a jejunostomy followed by an anastomosis to colonic remnant in the presence of ultra-short bowel due to proximal jejunal atresia. In Florence, we have recently switched our management to a more aggressive approach performing primary anastomosis to the colonic remnant.

However, in cases of complete midgut volvulus with extensive necrotic bowel or multiple intestinal atresias, we have always performed a resection instead of a more conservative approach such as the one reported by most of the European Pediatric Surgeons' Association members. We do understand that the main concern of the pediatric surgeon should be the preservation of the small bowel length and function, but our primary concern is to not leave nonviable bowel, worsening the prognosis in such a frail group of patients.

We request the author's opinion on our comments: we do appreciate and congratulate them for their innovative surgical effort in such a difficult and challenging field.

Publication History

Received: 29 March 2021

Accepted: 17 May 2021

Article published online:
09 July 2021

• References

• 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 Khalil BA, Ba'ath ME, Aziz A. et al. Intestinal rehabilitation and bowel reconstructive surgery: improved outcomes in children with short bowel syndrome. J Pediatr Gastroenterol Nutr 2012; 54 (04) 505-509
• 3 Lauro A, Coletta R, Morabito A. Restoring gut physiology in short bowel patients: from bench to clinical application of autologous intestinal reconstructive procedures. Expert Rev Gastroenterol Hepatol 2019; 13 (08) 785-796