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Autologous Reconstruction and Visceral Transplantation for Gut Failure Following Bariatric Surgery: 20 years of experience
Kareem M Abu-Elmagd1, Guilherme Costa*2, Ruy J. Cruz*2, Masato Fujiki*1, Koji Hashimoto*1, Neha Parekh*1, Ajai Khanna*1, Abhinav Humar2, John Fung1
1Cleveland Clinic, Cleveland, OH;2University of Pittsburgh Medical Center, Pittsburgh, PA

Bariatric surgery is currently the only long-lasting treatment for morbid obesity. However, these weight loss procedures could result in development of gut failure(GF) with need for total parenteral nutrition(TPN). This retrospective study is the first to address the anatomic and functional spectrum of bariatric surgery-associated GF with innovative surgical modalities to restore gut functions.
Over a 20-year period, 1,200 patients were referred with GF. Of these, 110(9%) had prior bariatric surgery; 97(88.3%) gastric-bypass, 5(4.5%) sleeve gastrectomy, 4(3.6%) gastric banding and 4(3.6%) jejunoileal-bypass. Causes of gut failure were major surgical complications(65%), dysmotility(25%), and malabsorption(10%). Catastrophic events included technical failure with gastric/enteric fistulae, internal herniation, and vascular thrombosis due to hypercoagulability. TPN duration ranged from 4 to 250 months. All patients were adults with 85% females. Multidisciplinary comprehensive medical and surgical rehabilitation was applied.

Foregut reconstruction was performed in all patients with gastrogastric(77%), gastroesophageal(13%), jejunoesophageal(7%), and colonic interposition(3%) anastomoses. Midgut reconstruction was required in 76% of patients. Bowel lengthening was performed in 16%. Visceral transplantation was utilized as a rescue therapy in 22(16%) patients with intestine alone in 16(73%) and composite visceral allograft in 6(27%). With mean follow-up of 52+34 months, 98% of surgically reconstructed patients and 73% of transplanted recipients were alive with achievement of full nutritional autonomy in 89%.
Gut failure is a potential complication of bariatric surgery due to a technically flawed operation and loss of gut homeostasis. Successful outcome can be achieved with major restorative surgical procedures including visceral transplantation as a rescue therapy.

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