Multiple intestinal anastomoses to avoid short bowel syndrome and stimulate bowel maturity in type IV multiple intestinal atresia and necrotizing enterocolitis

To the Editor, Multiple intestinal atresias and necrotizing enterocolitis (NEC) can lead to short bowel syndrome. The challenge in the neonatal period is to avoid surgical procedures that result in short bowel syndrome. Romao et al [1] have described the use of a transluminal stent and multiple intestinal anastomoses to preserve bowel length in such patients with favorable outcomes. In 1999, we reported our experience with multiple intestinal anastomoses without use of stenting in 6 patients [2]. All very short (b3 cm) and cordlike intestinal segments without a lumen were resected, and multiple anastomoses between the intervening intestinal segments and a side-to-end proximal chimney jejunojejunostomy, as described by Santulli and Blanc [3], were performed in 5 neonates with a type IV intestinal atresia and 1 with a NEC in an attempt to preserve bowel length. Without use of this technique of intestine salvage, the remaining length of small intestine would have been 28, 27, 40, 58, 70, and 7 cm. The procedure enabled an intestinal length of 49, 54, 96, 107, 92, and 93 cm, respectively, to be achieved. The ileocecal valve was present in all 5 cases of multiple intestinal atresias but was resected in the case with NEC. Early sham feeding was initiated in all 6 cases. The enterostomy was reversed after an average of 6 weeks (30-51 days) by end-to-end anastomosis with tapering of the dilated proximal segment in 3 cases. All 6 patients were weaned from parenteral nutrition after a mean time of 90 days (48-163 days). The prognosis was good with regard to growth and development, and length of time required before adaptation to normal enteral feedings and stools, with a mean follow-up of 31 months (14-57 months). Performing a Santulli-type enterostomy allowed progressive transanastomotic enteral feeding by slight flow of luminal nutrients, which had a trophic influence on the distal gut and stimulated maturity of bowel motility and function. These effects could similarly be observed by transluminal stenting as reported by Romao et al [1]. We believe that a potential advantage of transluminal stenting is that it obviates the need for stomas, as has been described by Yardley et al [4], avoiding the well-recognized risks of an enterostomy and the need for a second operation to reestablish intestinal continuity.