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Nutrition in Clinical Practice
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Invited Reviews

Nutrition Management of Small Bowel Transplant Patients

Rebecca A. Weseman, RD, CNSD, LMNT* and Richard Gilroy, MD, FRACP{dagger}

* Intestinal Rehabilitation and Transplant Programs, Nebraska Medical Center, Omaha, Nebraska; and{dagger} Department of Internal Medicine, Section of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska

Correspondence: Rebecca A. Weseman, RD, CNSD, LMNT, Intestinal Rehabilitation and Transplant Programs, 983285 Nebraska Medical Center, Omaha, NE 68198-3285. Electronic mail may be sent to Bweseman{at}nebraskamed.com.

Nutrition therapy after small bowel or combined liver/small bowel transplantation is challenging. The objective is to restore enteral autonomy to a patient with a complex past surgical history and equally complex posttransplant immunosuppressive regimen in the context of a newly created surgical anatomy. Improved surgical techniques and immunosuppressive regimens have led to superior outcomes. Accompanying these advances is a range of nutrition issues that require specific management strategies. This review outlines the current clinical practice and decision making used to create individualized nutrition regimens for small bowel or combined liver/small bowel transplant recipients. Successful small bowel transplant outcomes require a coordinated effort from a transplant team to restore nutritional autonomy to transplant recipients and free them from parenteral nutrition.

Intestinal failure is defined as, "the inability of the gastrointestinal tract to sustain life autonomously" and occurs when the small intestine is reduced below that amount necessary for adequate digestion and absorption of food and fluids.1,2 Although the absorptive function of the intestine does not always correlate with the residual bowel length, short bowel syndrome (SBS) anatomically requires intestinal resections leading to small intestine lengths <30% of normal, which in children is lengths <75 cm and <180 cm in adults.3 In addition to those with intestinal failure as a consequence of resected bowel, some less common causes of intestinal failure include mucosal abnormalities and motility disorders leading to malabsorption. Many of these patients require parenteral nutrition (PN) support, which is costly in terms of economic resources and can lead to great human suffering in terms of loss of freedom, reliance on central venous catheters, dependence on health care professionals to monitor their ongoing medical condition, frequent blood draws for laboratory monitoring, and a reduced quality of life.

Small bowel transplantation offers an alternative to PN; outcomes of small bowel transplantation continue to show improvement in the areas of patient and graft survival.4 This surgery is applied to patients with intestinal failure who are dependent on PN to sustain life and in whom complications of PN have developed to such a degree that they present as life threatening. In most cases, intestinal transplantation is not applied to people who tolerate PN without complications. Factors limiting the more generalized application of intestinal transplantation to all patients requiring PN include the lack of an adequate donor source, morbidity and mortality as a consequence of complications of the procedure, and the long-term side effects associated with immunosuppressive medications.5,6

Whether intestinal failure is caused by SBS or a nonfunctional gastrointestinal tract, health care professionals must understand the global impact of intestinal failure to minimize the complications encountered when managing these patients. This will help reduce the need for intestinal transplantation and perpetuate the research for nontransplant surgical therapies in improving enteral absorption in SBS (ie, intestinal lengthening and tapering procedures) and pharmaceutical agents (such as growth hormone or glucagon-like peptide-2, GLP-2) that may improve enteral adaptation and absorption in SBS. Despite improved results in intestinal transplantation, the surgical and hospital course remains expensive, and labor- and time-intensive. The nutrition management of these patients is complex and requires expertise. Most adult recipients are able to maintain adequate nutrition status posttransplant, and children maintain pretransplant growth velocity even though there is no evidence of catch-up growth. However, dehydration, malabsorption, and graft rejection influence the recipient's quality of life.7

Cost-effectiveness and outcomes of small bowel transplant and combined liver/small bowel transplant are directly related to the quality of the intestinal transplant program. Programs that specialize in liver transplantation are good models for intestinal transplantation because methods of immunosuppression and infection control are similar in both types of solid organ transplantation. The intestinal transplant team should consist of transplant surgeons, gastroenterologists, dietitians, pharmacists, and nurse clinicians.1 The focus of the team is to provide all modalities of intestinal rehabilitation and, when this fails, offer transplantation to those who develop complications of PN despite all therapeutic endeavors. To this effect, early intervention in an intestinal rehabilitation program may reduce the frequency and severity of PN-related complications.8

Despite newer immunosuppressive strategies that seem to have improved small bowel transplant short-term outcomes, the fact remains that a better understanding of the interaction of the small bowel graft's inherent immune system, luminal flora, and unique mechanisms that influence allograft outcomes is needed before a broader application of small bowel transplantation can be considered.9 The idea that patients who live high-quality lives despite being PN dependent, but desire to be considered for transplantation due to their individual quality-of-life issues, has been entertained.10 Intestinal transplantation is Medicare approved for patients in whom PN therapy has failed. At the present time, Medicare defines PN failure as the development of 1 or more of the following: liver failure, major vein thrombosis, frequent line-related sepsis, or recurrent and intractable dehydration leading to hospitalization. PN-associated liver disease is recognized as a major complication in long-term PN dependent patients. Abnormalities include steatosis and steatohepatitis, fibrosis, cholestasis, and cirrhosis. More than 50% of adult patients requiring PN for >5 years will develop some form of liver disease if PN dependent.11

A definitive cause for PN-associated liver disease remains unknown and is probably multifactorial in origin. Nutrition deficiencies in PN, potential toxic PN components, and a lack of protective elements such as choline likely contribute.12,13 The length of the remaining bowel remnant after intestinal resection has also been implicated; patients having very short remnants of bowel are at increased risk for liver dysfunction.11,14 Altered bile absorption, altered release of gut hormones, bacterial translocation, tumor necrosis factor associated with sepsis, and bacterial overgrowth are other potential factors.15


   Pretransplant
Top
 Pretransplant
Posttransplant
 Long-Term Nutrition Monitoring
 Conclusion
 
In situations of irreversible intestinal failure when intestinal rehabilitation efforts have been exhausted, patients may be considered for intestinal transplantation. It is unclear how many patients in the United States have SBS. Buchman and colleagues,16 in a technical review of SBS and intestinal transplantation, reported that approximately 26% (or 10,400 people) of all home PN patients require PN for SBS.16,17 These are data extrapolated from the Oley Foundation Home Total Parenteral Nutrition Registry maintained from 1985 to 1992. This would not include patient numbers for those who may have also had another disease process in addition to SBS such as malignancy or radiation enteritis or those who may have SBS but were successfully able to wean from PN.18,19

Disease Progress
Various precipitating factors may lead to short bowel syndrome (SBS) in adults as a result of surgical resection. This may be due to multiple resections for recurrent Crohn's disease, massive enterectomy made necessary because of a catastrophic vascular event such as a mesenteric arterial embolism or venous thrombosis, volvulus, trauma, or tumor resection. In children, SBS may result from a congenital condition such as intestinal atresia or from other conditions such a gastroschisis, necrotizing enterocolitis, or extensive aganglionosis. Chronic intestinal pseudoobstruction, refractory celiac disease, radiation enteritis, or congenital villous atrophy can cause functional SBS and severe malabsorption even if the bowel length remains intact20 (see Table 1).


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  		Table 1 Commonly reported indications for small bowel transplant

 

Contraindications to Transplant
Contraindications to small bowel transplantation include nonresectable or disseminated malignancy, unreconstructable vascular anatomy, diseases that are likely to recur after transplantation, profound disabilities that will not be corrected by transplantation, a loss of vascular access sufficient to allow transplantation, or an inability or unwillingness to comply with the rigors of the posttransplant management plan.21

Evaluation Process
The transplant evaluation process begins with an assessment of the complications of parenteral nutrition (PN) and the decision as to whether or not a patient's PN-related liver disease is reversible. This determination may be complicated to make, and considerations include the findings on liver biopsy and the likelihood of progression during the waiting period when trying to determine between performing a combined liver/small bowel transplant or an isolated small bowel transplant. The presence of dense bridging fibrosis would lead one to consider a combined liver/small bowel transplant. Minor amounts of fibrosis associated with cholestasis might allow isolated bowel transplantation. If, however, rapid progression of the disease has been seen and there is a predicted long waiting period (eg, in small infants), combined listing for liver/small bowel transplantation is likely required. Assessment for manifestations of portal hypertension is important, although diminished mesenteric blood flow secondary to remnant intestinal length provides protection against varices. Increasing splenomegaly, cytopenias, dilated superficial abdominal veins, and bleeding from gastrostomy sites or stomas provides clues to portal hypertension. The serum bilirubin level alone is not a good indictor as to whether isolated small bowel or combined liver/small bowel transplantation can be used. Isolated intestinal transplantation in jaundiced patients has been shown to reverse liver disease even in a patient with a total bilirubin of 20 mg/dL at transplantation.22

There is some controversy regarding the indication and timing for small bowel transplantation. In one evaluation of 42 patients with SBS (18 patients with 50–100 cm of small intestine plus colon, 14 patients with <50 cm small intestine plus colon, and 10 patients with <50 cm without colon), 1-year mortality rates were 50%, 72%, and 100%, respectively. Patients with very short remnant bowel lengths died due to multisystem organ failure in the early postoperative period or from sepsis23 (see Table 2). Intestinal failure patients with very short lengths of bowel require intensive monitoring to determine when referral for small bowel transplant needs to be considered.


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  		Table 2 Small bowel transplant patient evaluation process and goals

 

The evaluation process has several goals and will largely determine if patients have an indication for intestinal transplant or if referral to an intestinal rehabilitation program is more appropriate. An extensive medical and nutrition evaluation is required. It is not uncommon to see patients who have required long-term PN but may have never been monitored for micronutrient deficiencies.

During the nutrition evaluation and assessment as an integral component of the isolated or combined liver/small bowel transplant process, it is important to discuss with the potential recipient what they can anticipate regarding nutrition support and oral diet progression postoperatively. Various surgical techniques have been described and differ according to the transplant center. For example, in the effort to reduce the complication of gastroparesis seen during the early 1990s bowel-transplant experience, surgical techniques for combined liver/small bowel transplantation were modified at some centers to include a partial gastrectomy of approximately 50% of the native recipient's stomach.24 This technique reduces the often complex and frustrating issue of gastroparesis after a combined liver/small bowel transplant. When this surgical modification is made, the duodenum and head of the pancreas are retained in the allograft. With this type of surgical technique, diet modifications may be required to limit concentrated sweets and simple sugars such as fruit juice and gelatin, which might be considered as part of the standard early postsurgical diet therapy. A clear liquid diet may lead to increased ostomy fluid output with diarrhea, fullness, abdominal cramping, and patient discomfort due to hyperosmolar dumping into the intestine. Transplant candidates should be given an explanation of the diet and normal progression of nutrition therapy in the posttransplant course to reduce anxiety and potential frustration during this time. Some patients will also potentially retain gastric feeding tubes that may continue to be used for postsurgical enteral feedings or may have a feeding tube placed in the early posttransplant period to allow for enteral nutrition therapy. Patients should be allowed to ask questions or express concerns they may have regarding diet limitations they may have posttransplant. Most patients will have an ostomy created for surveillance of small bowel biopsies with restoration of continuity to their native colon several weeks after transplantation.24

Lymphoid tissue in the small bowel has been implicated in many of the difficulties of successful transplantation due to the intestine's heightened immune system and rejection response. Gut-associated lymphoid tissues (GALT) may increase the early interaction between donor antigens and recipient T cells.9 Immunosuppression for small bowel transplant recipients is based on tacrolimus therapy and usually administered to a trough level of 15–20 ng/mL by the end of the first postoperative week. The trough level is gradually lowered to between 5 and 10 ng/mL by 12 months' posttransplant.10 Corticosteroids are also part of the immunosuppressive regimen, at a typical dose of 20 mg/day for adults and 0.3 mg/kg/day for children. Graft rejection continues to be one of the most challenging management issues. Ostomy outputs are closely monitored for volume as this may be a clinical sign of graft rejection, infection, or viral-related illness due to cytomegalovirus (CMV), adenovirus, and Epstein Barr virus (EBV).20 In intestinal transplant clinical practice, close attention to the appropriate diet, oral fluid, and enteral nutrition can aid in reducing rapid intestinal transit and exacerbation of ostomy losses, along with improved immunosuppressive oral medication absorption. Ultimately, histologic criteria and surveillance biopsies are required to diagnose rejection, which include crypt cell injury, apoptosis, and a mononuclear cell infiltrate.10 Other markers for rejection have been reported, including intestinal fatty acid-binding protein, permeability studies, and serum citrulline levels, which are not dependent on changes in posttransplant nutrition therapy. However, serum markers may not be reliable, and biopsies are necessary to identify rejection early and allow for treatment.10,25

Pretransplant Nutrition Considerations
During the transplant evaluation process, the nutrition status of the potential transplant recipient should be thoroughly assessed and monitored periodically until the time of transplantation. Restoration of nutrient deficiencies, maintenance of an appropriate weight for height, treatment of osteomalacia, and assurance of mobility and functional capacity will potentially benefit the patient in the posttransplant recovery phase. During the transplant evaluation process, patients should be assessed for the appropriateness of the composition of PN prescription for the individual's requirements in macronutrients and potential nutrient deficiencies or toxicities. A complete assessment of fat-soluble and water-soluble vitamins should be conducted during the transplant evaluation process, along with essential fatty acid profile for triene:tetraene ratio, zinc, selenium, carnitine, and copper. In SBS with high ostomy outputs, zinc deficiency is often common and can easily be treated with supplementation in the PN prescription. Metabolic bone disease, cholestasis, and liver failure can be complications of PN failure. Metabolic bone disease, which occurs in as many as 15% of patients within a few months after becoming PN dependent, can lead to osteomalacia. This can cause debilitating bone disease, joint pain, vertebral compression, and pathologic fractures. Chronic cholestasis varies in frequency from 15% to 85% of patients requiring home PN. This may be due to the length of time receiving PN and the nutrition prescription and lack of adequate calcium and vitamin D absorption due to SBS.13

Osteoporosis has been reported in 67% of PN-dependent patients with intestinal failure and may also be linked to body mass index and duration of the SBS.26 Bisphosphonates given IV are now commonly used to maintain bone mass in short bowel patients. Monitoring for bone density and appropriate therapy before transplant will benefit patients as the posttransplant course with corticosteroid therapy as part of the dual immunosuppressive regimen will lead to increased calcium loss. Patients should be assessed for bone mineral density with dual energy x-ray absorptiometry (DEXA) during the evaluation process if they have not had a recent baseline measurement. Chronic and end-stage liver disease continues to occur in patients receiving long-term PN even though development of new PN formulations has been pursued to reduce the incidence of hepatobiliary dysfunction, especially steatosis. As with liver transplantation, combined liver/small bowel transplantation in the face of malnutrition leads to reduced graft function and an increase in the incidence of bacterial infections.27 Efforts should be made to replete patients nutritionally before transplantation.


   Posttransplant
Top
 Pretransplant
 Posttransplant
Long-Term Nutrition Monitoring
 Conclusion
 
Nutrition Considerations
Nutrition protocols are being developed for the small bowel posttransplant phase and have evolved as the surgical and immunosuppressive regimens have advanced. The main goal of intestinal transplantation is to aggressively work toward weaning PN support. In many cases, patients can be weaned from PN support within 1–3 months after transplant unless there is a complicated postoperative course with complications of rejection, infections (ie, cytomegalovirus or viral enteritis), or surgical setbacks. Unique issues to transplantation of the intestine can be extrinsic denervation, disrupted neural activity, disrupted lymphatic drainage potentially resulting in chylous ascites, and graft reperfusion injury. Clinical signs and symptoms during acute rejection most commonly include fever, nausea, vomiting, abdominal pain, increased stomal output, watery diarrhea, and metabolic acidosis. This increased loss of stomal output can have a profound effect on the adequacy of enteral nutrition absorption, which may require extended use of PN in certain pediatric or adult patients.28

PN
In the immediate postoperative period, recipients must be nutritionally supported with PN until the transplanted bowel ileus resolves, bowel sounds are present, and ostomy output is demonstrated. PN is initiated normally within 48 hours after surgery, when the patient is hemodynamically stable with stable blood pressure and fluid status. Patients require meticulous monitoring for adequate hydration via the PN support and other IV medications (ie, antibiotics) or IV fluid administration to assure provision of satisfactory perfusion to the transplanted graft and to replace nasogastric suctioning fluid losses. Serum electrolyte levels should be closely monitored and replacement given via PN and IV administration. Calorie and protein requirements are based on the patient's presurgical or estimated dry body weight. Initial goals are typically 150% of basal energy expenditure (BEE) for calories and 1.5–2 g protein per kg in adults. Indirect calorimetry should be conducted when there is suspicion of increased caloric requirements. In our clinical experience, measured resting energy expenditure (REE) tends to be greatly elevated over 150% of BEE. Nitrogen losses can be assessed with a nitrogen balance study to assure anabolism is achieved. PN support should be continued posttransplant until enteral feeding can be established at ≥50% of the individual's assessed requirements. The length of PN support required after transplantation will be determined in the case-specific assessment and largely dependent on the progression of enteral nutrition tolerance and incidence of complications or lack thereof. Frequently, PN is maintained for 1–2 months posttransplant.7

Fluids
A careful balance of fluid delivery is required to avoid excessive hydration or underhydration in the early postsurgical phase. Provision fluids from PN, medication administration, and supplemental IV fluids should be carefully weighed against the output volumes of urine, ostomy, nasogastric suctioning, emesis, and potential wound losses. Initially, 30–40 mL/kg/day should be provided with additional supplementation as the ostomy output increases after resolution of the posttransplant ileus.

Enteral Nutrition
Tube feedings are initiated when the postoperative ileus has resolved and ileostomy shows evidence of the return of bowel function. Typically, this is 5–7 days after transplant.7,29 If the transplant recipient has had a gastrostomy feeding tube before transplant, often this tube will remain to allow for enteral feedings in the posttransplant course; otherwise, a nasojejunal feeding tube may be placed when enteral feedings are ready to be started. A low-fat, moderate osmolality, elemental formula is generally started at full strength and low rate of 10 mL/h continuously in adults. The tube feeding should be increased slowly (eg, 10 mL increments per day) until the ultimate goal rate according to the individual is achieved. In our clinical experience, a low-fat formula for 4–6 weeks posttransplant is essential to avoid complications of chylous ascites due to the disrupted lymphatic system in transplantation of the intestine. However, this practice is not universal in all transplant centers. Enteral nutrition formulas containing primarily medium-chain triglycerides are generally preferred to allow for rapid intraluminal hydrolysis and absorption. Regeneration of the mechanisms involved in fat absorption is believed to occur within 4–6 weeks posttransplant, which is consistent with clinical practice observations.30 As the calculated goal rate of enteral nutrition is closely achieved, PN support should be incrementally tapered (see Table 3).


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  		Table 3 Nutrition support progression in adult intestinal transplant recipients

 

Oral Diet
Contrary to the common food aversion seen in pediatric intestinal transplant recipients who may have been sustained on PN and never learned to eat, adult recipients are often very anxious to begin an oral diet. Because the goal is to initially transition off PN while achieving the goal rate of tube feedings, the oral diet is limited in timing of initiation and lactose, sugar, fiber, and fat content. Patients are encouraged to start with small amounts of broth, hypotonic fluids (ie, tea, sugar-free flavored drinks, and gelatin). If the patient is tolerating enteral feedings well, the diet can be slowly advanced to complex carbohydrates, cooked and peeled fruits, low-fiber vegetables, and ultimately lean meats. At our center, a diet low in lactose, sugar, fiber, and fat is continued for 6 weeks after transplantation while monitoring the macronutrient intake of the oral diet to assure the appropriate reduction in enteral feedings as indicated to avoid overfeeding.

Many recipients can eventually liberalize their diet; however, it is not uncommon for an osmotic diarrhea to occur with hypertonic, high-sugar-containing beverages for an extended period. The patient must be taught to monitor his or her ileostomy output for excessive fluid losses to avoid the negative effect of dehydration on renal function. If the individual has some remaining colon, which can be restored in continuity with the transplanted bowel normally 6 months after transplant, this enhances ongoing enteral fluid absorption. The importance of educating patients to monitor their ostomy fluid losses, fluid intake, and urine volumes cannot be overstressed, because adequate hydration is essential in their long-term monitoring.

Glutamine
The clinical significance and utility of supplemental glutamine in the transplanted bowel remains uncertain. Because glutamine is the primary respiratory fuel for the enterocytes and the consumption of glutamine may increase in stress states, it seems reasonable to provide enteral nutrition containing at least minimal amounts of this amino acid. Glutamine may promote enhanced absorption of nutrients by assisting in the restoration of villous height and mucosal weight following reperfusion of blood supply in the intestinal graft.31,32 Glutamine may also promote brush border enzyme activity. At the very least, the provision of supplemental glutamine at a dose of 10–40 g/day in an adult can assist in attaining a positive nitrogen balance as enteral nutrition support is restored.33

Soluble Fiber
Fluid losses from the end ileostomy must be closely monitored to assure adequate replacement of excessive losses. Rejection of the graft after trans-plantation may result in a significant increase in stomal output. However, with proper initiation and progression of enteral feedings and an appropriate oral diet, limited in concentrated sweet and high-fructose juices, reasonable ostomy volumes are commonly seen. Ostomy outputs >1500 mL per day in an adult may require replacement with supplemental IV fluids.34 If the ostomy output is elevated in the absence of rejection, the addition of soluble fiber could benefit in slowing the intestinal transit time, enhancing surface contact time of enteral nutrients, and therefore enhancing fluid and nutrient absorption. At our center, the addition of soluble fiber is seldom required in the postoperative care; however, this therapy could be trialed according to the scenario of the individual with the addition of psyllium (10 g twice daily in adults) or guar gum (5 g 2–3 times daily).35

Fluid Balance
Collecting data on frequency, volume, and consistency of stools and the stool pattern in relationship to meal consumption provides information that can direct the medical and nutrition plan of care. Careful assessment must be made related to the individual patient's tolerance to fat, lactose, concentrated sweets, caffeine, and large meals. A major component of intestinal rehabilitation is to assess the fluid status of the individual patient. This comprises total fluid intake via PN, IV hydration, enteral feedings if being provided, and fluid consumed orally. Total output of fluid includes that lost in the stool or via ostomy output, urine volume, and insensible losses. Total fluid intake must at a minimum match the total fluid losses. Enteral balance considers fluids taken by mouth and that lost from the gastrointestinal tract. The goal for patients in the attempt to allow for PN weaning is to have the patient absorb oral fluid to remain in positive hydration status and minimize stool losses.


   Long-Term Nutrition Monitoring
Top
 Pretransplant
 Posttransplant
 Long-Term Nutrition Monitoring
Conclusion
 
Small bowel transplant recipients are often able to wean from PN and enteral nutrition support within 4 weeks and 8 weeks, respectively.36 Literature documenting the long-term nutrition outcomes of intestinal transplant recipients is lacking. In our clinical experience, monitoring of these patients with yearly serum laboratory values for fat-soluble vitamins, water-soluble vitamins, iron, ferritin, zinc, and selenium has been standard protocol. Patients should also have a baseline bone mineral density study in the perioperative period, with monitoring every 2 years to assure appropriate calcium and vitamin D supplementation is prescribed. Patients who may have received corticosteroids for a long period or at high doses pre- or posttransplant may also require bisphosphonates to reduce osteoporosis (see Table 4).


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  		Table 4 Suggested nutrition monitoring schedule for small bowel transplant recipients

 

Outcomes
The longest living small bowel transplant survivor is now approaching 15 years posttransplant.20 Three-year graft survival for isolated intestinal transplants is 73.1% and 39.2% for combined liver/small bowel transplant. The most common causes of death have been sepsis (46%), rejection (11.2%), technical problems (6.2%), and lymphoma (6.2%).20 It is felt that patient survival in combined liver/small bowel transplants is lower due to the issue of these patients being more critically ill before transplant. In addition, more patients die waiting for combined organ transplants than those waiting for single organ transplants.37 Infections are common complications associated with immunosuppression; conversely, the success of intestinal transplantation in the past decade has been in large part due to advances in immunosuppression.38,39 Summary analysis of liver and intestinal transplantation indicates intestinal transplants are being performed with increasing frequency and improved success as rejection and early graft losses have become easier to control (see Table 5). This, in part, is attributed to shorter cold ischemia times, younger patients being listed for small bowel transplant, and younger donor organs than previously, thus improving long-term survivals.39 The majority of intestinal transplant recipients can be weaned from PN support and maintained on enteral tube feedings, if required, and oral diet. In clinical practice, most transplant recipients indicate they feel their quality of life is improved after transplantation.


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  		Table 5 Summary of Intestinal Transplant Registry database, April 1985 to May 2003

 


   Conclusion
Top
 Pretransplant
 Posttransplant
 Long-Term Nutrition Monitoring
 Conclusion
 
Many patients with SBS can live quality lives while being PN-dependent. With the development of intestinal rehabilitation programs and centers of small bowel transplant excellence, SBS patients should undergo an extensive multidisciplinary evaluation with the potential for innovative research, nutrition and medical therapy, and surgical approaches to allow for PN weaning.3,40 If intestinal rehabilitation fails, small bowel transplant remains as a possible lifesaving option. Patients have undergone successful transplantation, despite maximal efforts of an intensive intestinal rehabilitation program to wean PN, and been restored to nutrition autonomy. Early referral to an intestinal rehabilitation program and transplant center is key in determining the best approach to a tailored plan of care for the individual who is PN dependent.

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Nutrition in Clinical Practice, Vol. 20, No. 5, 509-516 (2005)
DOI: 10.1177/0115426505020005509
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R. A. Weseman
Review of Incidence and Management of Chylous Ascites After Small Bowel Transplantation
Nutr Clin Pract, October 1, 2007; 22(5): 482 - 484.
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