Page 1 of 18
British Journal of Healthcare and Medical Research - Vol. 11, No. 5
Publication Date: October 25, 2024
DOI:10.14738/bjhmr.115.17810.
Amaro, D. E. L., Pazos, M. I. F., Barrón, G. M., Carrillo, C. A. Z., Montiel, A. F., Terrones, C. I. D., Román, L. V. M., Sixtos, J. R. L., Gómez,
J. R. D., Ambriz, I. R. M. de O., & Sánchez, M. A. G. (2024). Surgical Reflection Short Bowel Syndrome Truly Challenging. British Journal
of Healthcare and Medical Research, Vol - 11(5). 231-248.
Services for Science and Education – United Kingdom
Surgical Reflection Short Bowel Syndrome Truly Challenging
Dianna Estefany Lopez Amaro
Specialist in Surgery. Attached to the Department of Surgery of the General
Hospital "Dr. Rubén Leñero" of the Ministry of Health of Mexico City. Graduated
from the National Autonomous University of Mexico. Mexico City. Country:
Mexico
Mauricio Israel Flores Pazos
Specialist in Surgery. Attached to the Department of Surgery General Hospital
"Dr. Rubén Leñero" of the Ministry of Health of Mexico City. Graduated from the
National Autonomous University of Mexico. Mexico City. Country Mexico
Gema Méndez Barrón
Specialist in Surgery. Attached to the Department of Surgery General Hospital
"Dr. Rubén Leñero" of the Ministry of Health of Mexico City. Graduated from the
National Autonomous University of Mexico. Mexico City. Country Mexico
Carol Atzimba Zepeda Carrillo
Specialist in Surgery. Attached to the Department of Surgery General Hospital
"Dr. Rubén Leñero" of the Ministry of Health of Mexico City. Graduated from the
National Autonomous University of Mexico, Mexico City. Country Mexico
Angel Flores Montiel
Specialist in Surgery. Attached to the Surgery Department of the General Hospital
of the Ministry of Health of Mexico City. "Dr. Rubén Leñero" Graduated from the
National Autonomous University of Tlaxcala, Mexico City. Country Mexico
Carlos Iván Díaz Terrones
Specialist in Surgery. Attached to the Surgery Department of the General Hospital
of the Ministry of Health of Mexico City. "Dr. Rubén Leñero" Graduated from the
Justo Sierra University Center, Mexico City. Country Mexico
Laura Valeria Medina Román
Specialist in Surgery. Attached to the Surgery Department of the General Hospital
of the Ministry of Health of Mexico City. "Dr. Rubén Leñero" Graduated from the
National Polytechnic Institute, Mexico City. Country Mexico
Jaime Ricardo López Sixtos
Specialist in Surgery. Attached to the Department of Surgery General Hospital
"Dr. Rubén Leñero" of the Ministry of Health of Mexico City. Graduated from the
National Autonomous University of Mexico. Mexico City. Country Mexico
Page 2 of 18
232
British Journal of Healthcare and Medical Research (BJHMR) Vol 11, Issue 05, October-2024
Services for Science and Education – United Kingdom
Jesús Ricardo Delgado Gómez
Specialist in Surgery. Attached to the Department of Surgery General Hospital
"Dr. Rubén Leñero" of the Ministry of Health of Mexico City. Graduated from the
National Autonomous University of Mexico. Mexico City. Country Mexico
Iñaki Rubén Montes de Oca Ambriz
Specialist in Surgery. Attached to the Department of Surgery General Hospital
"Dr. Rubén Leñero" of the Ministry of Health of Mexico City. Graduated from the
National Autonomous University of Mexico. Mexico City. Country Mexico
Morelos Adolfo García Sánchez
*Specialist in Surgery and with a Subspecialty in Colon and Rectal Surgery
attached to the Surgery Department of the General Hospital Ministry of Health of
Mexico City. "Dr. Rubén Leñero". And Graduated from the National Autonomous
University of Mexico, Mexico City. Country Mexico
INTRODUCTION
It is complex to tacitly define the so-called short intestine (SI), where the real length of it is the
guideline to carry out its function, this will depend on many factors at the time of its counting
or evaluation, since it is not exact or reliable and the calculation is very subjective in arithmetic
or absolute terms, being impossible or practically fatuous. SI has been defined as those patients
who have had an intestinal resection and who are left with a short length, approximately 200
cm or less of the remaining small intestine by counting from the ligament of Treitz. [1, 2]
Minimizing bowel resection at initial surgery and restoring bowel continuity through ostomy
reversal can effectively decrease the time to early enteral autonomy and avoid short bowel
syndrome (SBS). [3]
There is the concept of SBS is divided into anatomical (A) by its length (with less than 100 cm)
and/or physiological short bowel syndrome (P) than by its length (with less than 200 cm). SBS
is a condition that results from a reduction in the length of the intestine or its functional
capacity. Therefore, its definition must be clear, precise and forceful, which for different or
varied reasons must be adapted to each patient. [4] SBS is a rare disorder with known physical,
psychosocial, and economic burdens, with significant morbidity and mortality. Many people
with SI require long-term home parenteral nutrition, decimating any health system, patients,
and families, who report substantial financial distress that affects quality of life. [5]
ANATOMY AND PHYSIOLOGY
The small intestine is a crucial gastrointestinal segment involved in digestion and nutrient
absorption, as well as various endocrine functions and immune protection; with a complex
structure of blood vessels, nerves, muscles, and special cells, which work together to allow the
small intestine to accomplish these tasks. [6] The small intestine has three portions: which is
duodenum, jejunum, and ileum, 4 to 5 centimeters wide and 6 to 7 meters long (the duodenum
is 25 to 30 cm). The colon or large intestine is on average 10 centimeters wide, with a total
length of 120 x 160 cm in total. [7, 8]
The normal length of an adult's small intestine, starting from the duodenum-jejunal angle,
measures between 275 and 850 centimeters. About 9 liters of fluid pass through the small
Page 3 of 18
233
Amaro, D. E. L., Pazos, M. I. F., Barrón, G. M., Carrillo, C. A. Z., Montiel, A. F., Terrones, C. I. D., Román, L. V. M., Sixtos, J. R. L., Gómez, J. R. D.,
Ambriz, I. R. M. de O., & Sánchez, M. A. G. (2024). Surgical Reflection Short Bowel Syndrome Truly Challenging. British Journal of Healthcare and
Medical Research, Vol - 11(5). 231-248.
URL: http://dx.doi.org/10.14738/bjhmr.115.17810.
intestine daily in the form of oral fluids, saliva, gastric, biliary, and pancreatic secretions. On
average, about 7 liters of those fluids are absorbed in the small intestine and 2 liters in the large
intestine. The healthy large intestine absorbs approximately 150 kilocalories per day but can
absorb up to 1000 kilocalories per day in those patients with malabsorption. The absorption of
most nutrients occurs in the first 100 centimeters of the jejunum. Vitamin B12 and bile salts are
absorbed in the last 100 centimeters of the ileum; magnesium is absorbed in the terminal ileum
and proximal colon; the absorption of water and sodium takes place throughout the intestine.
[9] The large intestine is the part of the digestive tract where water from indigestible contents
is absorbed. The large intestine includes the cecum, appendix, entire colon, rectum, and anal
canal. Key functions of the colon include the following: absorption of water, nutrients, and
vitamins, compaction of stool, secretion of potassium, chloride, and moving waste material into
the rectum. [10]
Diet quality affects gut homeostasis by influencing microbiota, intestinal permeability, and
lipopolysaccharide clearance; therefore, dietary patterns could favor or protect against
metabolic endotoxemia, bacterial translocation and intestinal permeability itself. [11]
HOW TO MEASURE THE LENGTH OF THE SMALL INTESTINE
Although there is a difference in measurement techniques and the size of study groups, most
research that measures the length of the small intestine employs direct techniques using
methods such as U-ribbon; ranging from the ligament of Treitz to the ileocecal valve, the mean
length of the small intestine measured was 615.4 cm (623 cm for 494 men and 611.4 cm for
895 women, respectively), while the average diameter was 2.3 cm; whose measurement was
carried out with artificial intelligence software in an abdominal computed tomography. [12] In
addition, it should be considered that intestinal length can vary from one subject to another due
to the same constitution, weight, height, or being male or female, or age, or genetic or hereditary
pathologies and previous emergency or scheduled surgeries. [13]
The current gold standard for small bowel measurement in humans is intraoperative
evaluation performed by an experienced surgeon. However, even measurements made in the
operating room are notoriously unreliable. [14] Surgeons primarily use their visual estimation
of distances to measure bowel length, or two-dimensional vision in laparoscopic surgery;
where the lack of depth perception impairs the accuracy of the visual estimation of intestinal
distances by surgeons, concluding an error factor of up to 30%. Although robotic surgery
consoles offer three-dimensional vision, their impact on the accuracy of distance estimation is
not yet fully understood. [15] Evaluation of the length of the remaining small intestine by three- dimensional computed tomography is the most accurate and acceptable method in the end, for
clinical application; while intestinal transit with barium is less precise, however, it is more
convenient and economical in a condescending manner in an institutional/public clinical
reality. [16]
Therefore, non-invasive measurement of the length of the small intestine is challenging. Three- dimensional imaging modalities reduce the risk of length underestimation, which is common
with two-dimensional techniques. However, they also require longer times to make length
measurements. Automated segmentation has been tested for magnetic resonance
enterography. [17] Where the length of the small intestine by computed tomography or
magnetic resonance enterography allows with this method to reconstruct two- and three-
Page 4 of 18
234
British Journal of Healthcare and Medical Research (BJHMR) Vol 11, Issue 05, October-2024
Services for Science and Education – United Kingdom
dimensional curves multiplanar and achieves the stretching of each intestinal loop, by means
of a point-to-point identification of the intestinal lumen. Subsequently, the software allows the
creation of a virtual image, on which the intestinal length is measured linearly with greater
precision. [18]
ETIOLOGY OF SHORT BOWEL SYNDROME
In the first instance, congenital SBS (C) is a genetic mutation of Phylamine A (FLNA) with CSBS,
which is a rare disease with a very poor prognosis. [19] Not to mention that the dimensions of
the small intestine and the large intestine can be altered by the following causes, such as
dilation or extension or a great elongation when there is an existing pathological condition or
the combination of two or more of them such as: an intestinal occlusion, [20] paralytic ileus,
severe systemic malnutrition, previous specific surgeries, [21] a restrictive and/or selective
diet, mesenteric ischemia, metabolic or chronic-degenerative diseases or inflammatory bowel
diseases, [22] cancer, [23, 24] necrotizing enterocolitis, volvulus malrotation, intussusception
or idiopathic causes, [25] among many others.
We must not forget to mention the jejunal stomas, which are very high or close to the ligament
of Treitz, which some surgeons do in an emergency surgery or even erroneously scheduled or
because they have no other option in a damage control surgery in the practice of trauma
surgery, and that results in SBS in the patient. [26] In mesenteric ischemia due to infarction or
thrombosis, anticoagulant therapy is initiated in 68% of cases, but most surgical teams choose
between 96% and 86% a major bowel resection when there are obvious signs of extensive
necrosis. [27] See Figure 1.
Figure 1: Massive intestinal ischemia with necrosis of the small intestine and colon.
Non-occlusive mesenteric ischemia is a fatal disease with a low survival rate in most cases, it
occurs due to spasms or diffuse narrowing of the peripheral arteries, which ultimately leads to
necrosis of the intestine; where being able to determine the exact extent of the intestinal
resection is essential, with the utility of fluorescence, (sodium fluorescein and black light) [28]
then projecting an additional intestinal resection in a second operation for a revision, at 48 or
72 hours; but it should be clarified that nothing is established at this time. [29]
Page 7 of 18
237
Amaro, D. E. L., Pazos, M. I. F., Barrón, G. M., Carrillo, C. A. Z., Montiel, A. F., Terrones, C. I. D., Román, L. V. M., Sixtos, J. R. L., Gómez, J. R. D.,
Ambriz, I. R. M. de O., & Sánchez, M. A. G. (2024). Surgical Reflection Short Bowel Syndrome Truly Challenging. British Journal of Healthcare and
Medical Research, Vol - 11(5). 231-248.
URL: http://dx.doi.org/10.14738/bjhmr.115.17810.
hypomagnesemia, hypokalemia, and vitamin deficiency, leading to cardiorespiratory failure,
malignant arrhythmias, neuromuscular symptoms, hematologic dysfunction, and death. [45,
46] Prolonged fasting induces histological and ultrastructural changes that are reflected in
decreased absorption in the intestine (duodenum and jejunum). This includes villi shortening
with or without mucosal atrophy resulting from degenerative changes in individual
enterocytes. [47]
A high volume of ileostomy/jejunostomy effluent in patients with extensive bowel resection
may be difficult to control. This leads to extensive loss of proteins, fluids, and electrolytes along
with consequent malabsorption. The strategic use of drugs has traditionally been controlled by
delaying intestinal transit, reducing intestinal and gastric secretion using opiates, loperamide,
diphenoxylate, omeprazole, hyoscine butyl bromide, somatostatin and octreotide. [48, 49]
Intestinal adaptation becomes both a morphological and functional mechanism, in which there
is an increase in the depth of the crypts and lengthening of the intestinal villi to provide a
greater absorptive surface, with the conjugation of dietary changes and intestinal or colonic
biota. The global process of intestinal adaptation occurs in 3 phases:
1. Survival or phase I: from 2 weeks postoperative to 2 months. Equalizing the hydro
electrolyte imbalance.
2. Intestinal retraining or phase II lasts from 2 months to 2 years, with a mixed diet both
enteral and parenteral.
3. Intestinal stability or phase III: nutritional and metabolic stability is achieved. More
than 2 years until normalization with nutritional self-sufficiency or with minimal
supplementation by oral intake. [50]
Patients with high proximal stoma often rely on total parenteral nutrition, which is expensive
and risky. Distal enteral tube feeding is a method of delivering nutrition to the small intestine
that aims to improve clinical outcomes and reduce complications, with a significantly shorter
total hospital stay as in the intensive care unit, with less time for total parenteral nutrition
(mixed nutrition) and a significantly faster time to closure or full recovery. [51]
On the other hand, bowel resection in an infant has a better prognosis, due to the potential for
intestinal growth and adaptation. It is a determinant of intestinal functionality and prognosis,
since in the neonatal period the probability of achieving independence from parenteral
nutrition is 88% in >50cm of jejunum, 60% in >38cm and 7% in <15cm. In intestinal length
<50cm, the probability of discontinuation of parenteral nutrition is 23% after 12 months, 38%
at 24 months and 71% at 57 months. [52, 53] The 5-year mortality rate was estimated at 10.1%
in patients with non-malignant intestinal failure, and by age the incidence was classified as
89.1% for those under 40 years of age, 74.8% for patients between 40 and 60 years of age, and
52.1% for those over 60 years of age; inflammatory bowel disease as a significant risk factor for
increased mortality. In addition, gut anatomy was significantly associated with the weaning
ability of parenteral nutrition, and no patient without a colon and with a remnant of less than
100 cm of the small intestine remained weaned continuously and alive for one year. [54] In
another study, the relative survival that has been achieved was 76%. In patients with long-term
intestinal failure, as a cause of death that occurred during home parenteral support, in adult
patients for non-malignant reasons. [55]