Nutritional Challenges in Patients After Intestinal Auto-Transplantation and Ex-Vivo Surgery

Introduction: Intestinal auto-transplantation (IATx) and ex-vivo surgery is a novel surgical strategy to treat patients with conventionally unresectable abdominal neoplasms involving the mesenteric root. Adequate nutrition after surgery is crucial, but major surgery and early motility problems can delay the initiation of oral diets and warrant supplemental parenteral (PN) and/or enteral nutrition (EN) for protracted durations. Nutritional challenges after IATx and ex-vivo surgery have not previously been well-described. Methods: Eleven patients aged 7 to 68 (median, 49) underwent IATx and ex-vivo surgery at our center from 2009 to 2016. A retrospective chart review was performed to evaluate nutritional status, tolerance of an oral diet and need of PN and EN support. These factors were assessed both pre and peri-operatively as well as at 3 months post-operatively. Results: Six patients underwent isolated IATx, and 5 underwent both liver and IATx. Seven patients are currently alive without evidence of disease with a median of 7 years follow-up. Prior to surgery, 10 out of 11 patients were tolerating oral diets without need for additional PN or EN. Pre-operative BMI ranged from 14.6-30.4 (median, 20.9). Post-operatively, PN was initiated in all patients from 1-15 days after surgery (median, 5) and continued from 12-122 days (median, 32.5) with the exception of one patient who underwent a total enterectomy and required subsequent allotransplantation with ongoing PN use. EN was initiated in nine patients from 4-117 days after surgery (median, 17). Enteral supplementation has been ongoing in 7 patients and weaned off completely in 2. One patient was started directly on an oral diet without EN and another required allotransplantation with ongoing PN use. Oral diets were initiated in all patients from 5 -115 days (median, 14) after surgery and at 3-month follow-up, all patients were tolerating oral diets, with BMI ranging from 15.2-27.7 (median 18.5). Conclusion: IATx and ex-vivo surgery presents a unique challenge with respect to nutritional management. Patients undergoing these complex surgeries may have difficulty maintaining adequate nutrition with an oral diet alone in the immediate post-operative period and beyond, and may require prolonged support with PN and EN. Nutritional status must be closely monitored and optimized accordingly in this population.