Nutritional outcomes following small bowel transplantation – The first year post-operative nutritional nadir

Background: It is broadly appreciated that nutritional impairment can adversely affect the outcome of major surgery. The nutritional nadir following small bowel transplantation (SBT) represents the worst case scenario, and there may be advantages in reducing the impact of this risk factor. The aim of this analysis was to describe the nutritional outcomes of adult patients following SBT. Methods: Between 2006 and 2012, 13 patients received small bowel or multi-visceral transplantation at our centre. Longitudinal anthropometric data were routinely collected to assess nutritional status and allow timely intervention if appropriate. Results: 13 patients (10 M, 3 F) had 15 transplants. 5 (33.3%) were isolated SBT, 9 (60.0%) were multi-visceral and 1 (6.7%) modified multi-visceral transplant. Mean age at SBT is 41.6 years (SD 9.5; range 29 to 60 years). Mean duration of nutritional follow up was 453 days (SD 366; range 60 to 1034 days). 7 patients (53.8%) were on parenteral nutrition (PN) pre-transplant, with 4 (30.1%) on oral nutritional supplements. Mean handgrip (age and gender adjusted) pre-transplant was 67.5% (SD 17.9%). Anthropometric studies were carried out on average 209 (SD 173) days pre-transplant. Mean duration of PN post transplantation was 26.9 (SD 33.4) days, with median 18 days. 10 patients maintained nutrition orally in the long term, 2 patients required enteral supplementation, 1 (who had subsequent small bowel infarct and enterectomy) required parenteral support. Mean handgrip strength reduced by 13.8% (SD 19.2) in the initial 3 months post transplantation, and improved by 6.5% (SD 15.9) within 6 months, 6.6% (SD 15.9) within 12 months, 8.5% (SD 27.4) within 24 months, 15.3% (SD 13) after 24 months. If the two deceased patients were excluded, there was significant improvement in handgrip strength on student t test (p value 0.047). Pre-operative (pre-op) parameters were compared to the lowest post-operative (post-op) values found in the first year (the nadir). Body weight (BW) fell significantly from a pre-op mean of 64.6 (SD14.4) kg to a post-op mean of 58.8 (SD 11.96) Kg, with Wilcoxon signed rank test (WSR) 0.016 (2 tailed). 10 patients experienced a fall in BW, with mean -10.72 (SD 8.3)% and 2 a rise, with mean 14.2 (SD7.6)%. This resulted in overall mean change (CI) of -6.8(-14.3 – 0.53)%. There was a significant fall in body mass index, with mean (CI) from 21.5(19.4 – 32.6) to 19.7(17.8 – 21.6); WSR = 0.033. The maximum individual fall in BW and BMI in the first post-operative year were measured at 25.8% and 25% respectively. As the majority received small bowel repletion the post-operative weight loss may be underestimated. Interestingly in our series this was not associated with a significant fall in MAC, MAMC and triceps. Conclusion: Longterm nutrition can be maintained with oral intake in the majority of patients post SBT. There is significant improvement to handgrip strength post transplant which remains an important marker of clinical nutritional status. Transplantation does not significantly alter other common anthropometric markers. When preparing patients for SBT the potential severe loss of BW and BMI should be an important consideration in the timing of surgery. There may be merit in delay of surgery in certain cases to allow improvement in nutritional status.Table 1Handgrip post transplant.Months post transplant0-33-66-1212-24Over 24Mean % improvement in handgrip-13.8 (SD 19.2)6.5 (SD 15.9)6.55 (SD 15.9)8.5 (SD 27.4)15.3 (SD 13)Median % improvement in handgrip-21.46.58813 Open table in a new tab