The Soy-Eating Lion

I have not failed. I’ve just found 10,000 ways that won’t work.

Thomas A. Edison

The first description of intestinal failure (IF) was reported by Flemming and Remington in 1981 to describe a state of “reduction of bowel function below the minimum level to allow a correct state of digestion and absorption of nutrients”.

Later the European Society for Clinical Nutrition and Metabolism (ESPEN) updated the definition of intestinal failure as “the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth”.

We need to remember that intestinal failure is not the same as bowel insufficiency or deficit, defined by ESPEN as “the reduction of the gut’s absorptive function that does not require any intravenous supplementation to maintain health and/ or growth”.

After a brief overview of the whole problem, we will focus on type 2 intestinal failure, the real nightmare for general surgeons!

Intestinal Failure Classification

Intestinal failure can be classified based on anatomy, physiopathology, clinical condition, or functional status.

Functional classification is the one that let us divide IF into three categories according to duration and clinical severity:

• Type 1 or acute
• Type 2 or severe acute
• Type 3 or chronic

Acute IF accounts for about 90% of IF, considering Type 1 and 2 together. Those conditions are usually treated within the hospital (mostly by surgeons). On the other side, chronic IF (i.e. Type 3) is usually managed with total parenteral nutrition as home care.

Type 1 IF comprises patients with postoperative ileum or intestinal sub-occlusion/occlusion that would resolve within a few days of intravenous nutritional support.

Type 2  IF lasts more than 28 days by definition, and it usually includes patients with a long in-hospital history of intensive care unit stay, with septic abdominal complications after surgery, with complex Crohn’s disease, and/or with multiple bowel fistulas of different kinds. Those patients require a multidisciplinary approach and management, even though they are pretty infrequent (luckily for them, and for us). 

Most frequently, in about 28% of cases, Type 3 IF derives from the chronicization of Type 2 IF. Among the other bowel conditions leading to the development of a Type 3 IF, neoplasms and radiation enteritis have the worst long-term prognosis with a survival rate of about 62% at 1 year.

The three types of IF may be seen as a single continuous process that may potentially develop from an “innocuous” Type 1 ileum. This is why many guidelines suggest performing a CT scan after the 5^th postoperative day to exclude septic intraabdominal complications such as collections, intestinal lesions, or anastomotic leakage.

If an intervention is needed, the probability of intestinal resection, intestinal fistulas, or stomas is high. These events may lead to the patient’s nutritional deficit and the necessity for endogenous nutritional support (i.e. Type 2 IF). If not rapidly reversed, the risk of entering the Type 3 IF is right behind the corner…

How Can We Prevent IF?

By international consensus, IF is defined as the result of obstruction, altered intestinal mobility, surgical resection, congenital defects, or diseases where absorption is altered.

Prevention measures are:

• Meticulous patients selection (preoperative patients selection and preparation, physical and nutritional support);
• Reduction of surgical-related risks (correction of hypoproteinemia, suspension of immunosuppressive drugs), choose non-invasive or minimally-invasive procedures (e.g. antibiotics and/or radiologically-guided drainage);
• Accurate surgical technique (intestinal revision before closing, anastomosis with low numbers of sutures, damage control protocols for unstable patients);
• Rapid recognition of surgical complications, and prompt and proper treatment;
• Anticipation and avoidance of intestinal lesions during emergency redo surgeries.

The Stanford Hospital’s Intestinal Failure Unit reports in one of its articles that between 2002 and 2005 the most frequent causes of IF were:

Apparently, during the last years, other causes gained importance, such as complications of laparoscopic adhesiolysis, laparoscopic hernia and bariatric surgery.

Type 2 Intestinal Failure – Severe Acute

Type 2 IF has an unknown incidence over the globe since there are no strict diagnostic tools, a lack of referral centers, and most of the time it comes from surgical complications (which surgeons tend to occult). In England, the estimated incidence is 1,500-2,000 hospitalizations/year with a prevalence of 9/1.000.000 habitants (this comes from the numbers of patients receiving NPT longer than 28 days).

Type 2 IF results from a catastrophic sequence of extensive intestinal resection/-s, abdominal sepsis, inflammatory bowel disease, and bowel fistulas, creating a poor nutritional status with the necessity of endogenous supplementation.

The principal consequences of a longstanding Type 2 IF are:

• Low nutritional status;
• Social stigma (e.g. enterocutaneous or enteroatmospheric fistulas);
• Decrease in life expectancy;
• NPT correlated complications.

As we already said, a Type 2 IF usually starts with a bowel injury or an unknown anastomotic leak. From it, incorrect management leads to intra-abdominal sepsis, reoperations, new intestinal injuries, and, eventually, stoma or fistula creation.

In the setting of acute care surgery, where there is a frequent need for an open abdomen, the rate of Type 2 IF is quite different depending on the underlying indication (trauma vs. abdominal sepsis). In fact, less than 5% of traumatic open abdomens develop IF, whereas more than 10% of septic open abdomens lead to Type 2 IF.

Management of Type 2 Intestinal Failure – SNAP

Nightingale and Woodward have come across four targets to achieve during the management of these patients:

1. Nutritional, electrolyte, and water support to maintain a good health status;
2. Reducing the severity of the IF;
3. Preventing and properly treating IF complications;
4. Looking for a good patient’s quality of life;

To achieve these goals a progressive sequence of steps must be followed according to the acronym SNAP: Sepsis, Nutrition, Anatomy, Plan.

A. Sepsis and Skin Care

The first step is sepsis control together with skin care for 2 reasons:

1. A permanent septic status blocks the metabolism, conditioning a continuous catabolic status with resistance to the anabolic insulin effect;
2. These patients may have a rapid evolution to severe complicated sepsis which is responsible for 70% of the deaths in IF-specialized units.

Patients with Type 2 IF may not present the classic symptoms of sepsis (i.e. fever, tachycardia, tachypnea, and/or leukocytosis), but they will develop signs as persisting hypoalbuminemia, hyponatremia, the elevation of inflammatory markers, alteration of the liver function (e.g. hyperbilirubinemia without a cause), or cachexia despite correct nutritional support.

Sepsis treatment key points are:

• Antibiotic treatment, as much as possible guided on cultures;
• US- or CT-guided drainage of intra-abdominal collections;
• Surgical drainage should be performed only when interventional radiology is not pursuable (for technical issues or patient conditions deterioration).

When facing a rescue surgery situation, the creation of a proximal stoma or an open abdomen should be taken into consideration. However, even when correctly indicated, the risk of fistula development or subsequent difficult abdominal wall reconstruction should be always thought of. This is never an easy decision to take, considering that proper strict indications are still lacking. We still have a lot to define about it in the future!

In every patient living with a stoma, the role of specialized stoma nurses is vital for stoma management and education!

B. Nutrition and Medical Treatment

Nutritional optimization is one of the key steps because:

1. Patients with type 2 IF are usually in a very low nutritional status (i.e. BMI <18,5);
2. After persistent septic status, “malnutrition” is the most important factor for low immunological response and slow wound healing.

Up to now, no standard has been chosen to correctly evaluate the nutritional status and recovery in these patients. BMI is highly influenced by fluid overload, septic status, and/or biochemical parameters such as albumin and prealbumin levels.

Some authors proposed using the loss of weight and the calculation of corporal composition (i.e. fat/muscle rate) as the method to assess the nutritional status. However, studies supporting this are still lacking.

So, what is usually done is an estimation of daily calories, micronutrients, and proteins needed for each patient. With this method, there is a risk of refeeding syndrome!

Nutritional supplementation may be obtained in different ways. Usually, a mix of them is used to achieve the correct patient support:

• Enteral Nutrition (EN): this is the best nutritional way for patients with more than 80 cm of functional bowel. It avoids parenteral nutrition complications and hit as a better patient psychological outcome. In patients with high-output proximal fistulas, supplementation from the distal stoma/fistula or eventually with the same proximal fistula output (i.e. fistuloclysis) should be considered;

• Parenteral Nutrition (PN): it is the most frequent nutrition method for patients with Type 2 IF, but it is associated with a high complication rate. Nonetheless, it is the method of choice for acute/severe situations and long-lasting IF.

Parenteral nutrition complications may be:

1. Thromboembolism;
2. Catheter infection (lower rates with tunneled catheters);
3. Metabolic bone disease; a combination of vitamin D deficiency and chronic inflammatory status leads to osteoporosis in almost 45% of patients with a long necessity of PN;
4. Hepatic dysfunction:
   • Sepsis-related;
   • Drugs-related;
   • Rapid weight loss (steatosis with caloric/protein malnutrition);
   • Hypertransaminasemia due to PN during the first few weeks, but with a rate of persistent alteration of 39-52% (steatosis, intrahepatic cholestasis, portal hypertension);
5. Intestinal failure-associated liver disease (IFALD): liver involvement secondary to intestinal failure and association with PN. Screening for other possible causes of liver disease is mandatory. IFALD encompasses a broad spectrum of liver conditions: altered liver enzymes, steatosis/steatohepatitis (NAFLD/NASH), intrahepatic cholestasis, progressive fibrosis, cirrhosis, portal hypertension, and, finally, liver failure requiring a transplant. Up to 1-4% of deaths of patients with IF in PN support are associated with IFALD. The diagnostic gold standard is liver biopsy.

C. Anatomy and Functional Study

The goal is to map the bowel in order to plan the following surgery and increase its success rate. It is essential to know the position of the fistula/stoma (length of proximal and distal bowel segments) and if there is any distal stenosis.

This mapping is obtained using CT or MR images with IV as well as intraluminal contrast.  Fistulogram, urogram, and cholangiogram should be used to study extra-intestinal fistulas.

D. Plan

A multidisciplinary approach is needed to create a patient-centered plan. Dieticians, pharmacologists, nurses, stoma therapists, microbiologists, radiologists, pain doctors, pathologists, rehabilitation specialists, psychologists, and surgeons should be involved.

Key points are:

• Treating the underlying pathology and intercurrent or coexisting processes;
• Considering the possible short bowel syndrome (i.e. <200 cm of actively functioning bowel) when definitive surgical treatment is planned.

Surgery will be complex, long, and with a high risk of multiple procedures.

Its goals are:

• Restoring gastrointestinal continuity to regain nutritional autonomy;
• Resection of fistula tracts;
• Adhesions release;
• Abdominal wall reconstruction (high risk of postoperative enteroatmospheric fistulas in patients with previous open abdomen);
• Intestinal transplant (lack of major publications).

The OR should be postponed “as much as possible”. A rushed surgery may lead to more intra- and postoperative complications. This is an ultramarathon!
The surgical insult should be delayed for 6-12 months from the last surgery. During these months, the patient will have to re- and pre-habilitate for the next hospitalization.

As we hope you understand, a whole sea of problems is connected with intestinal failure… Luckily for humanity, the percentage of patients affected by this condition is low… Meaning there is no shame in asking for help!

See you next time…

Namasté!

References

1. Lal S, et al. Review article: Intestinal failure. Alimentary Pharmacology and Therapeutics 2006;24:19-31.
2. Soop M, et al. Intestinal failure. Coloproctology. 2^nd Ed. Heidelberg, Germany: Springer-Verlag Berlin; 2017.
3. Bond A, et al. Review article: diagnosis and management of intestinal failure-associated liver disease in adults. Alimentary Pharmacology and Therapeutics 2019;50:640-53.
4. Allan P, et al. Intestinal failure: a review. F1000Research 2018;7(F1000 Faculty Rev):85.
5. Adaba F, et al. Management of intestinal failure: the high-output enterostomy and enterocutaneous fistula. Clinics in Colon and Rectal Surgery 2017;30:215-22.

How to Cite This Post

Vidal A, Bellio G, Marrano E. The Soy-Eating Lion. Surgical Pizza. Published on February 5, 2023. Accessed on May 27, 2023. Available at [https://surgicalpizza.org/rescue/the-soy-eating-lion/].