The Bianchi procedure is a surgical technique designed to lengthen the small intestine. This intervention aims to help individuals with short bowel syndrome (SBS) reduce or eliminate their reliance on intravenous nutrition, known as total parenteral nutrition (TPN). It is a procedure that can significantly improve a patient’s health and quality of life.
Understanding Short Bowel Syndrome
Short bowel syndrome (SBS) is a condition where the small intestine is too short or damaged to absorb enough nutrients, fluids, and electrolytes to sustain the body. The normal length of the adult human small intestine ranges from 260 cm to 800 cm, with an average of about 600 cm. SBS can occur if less than 200 cm of viable small bowel remains, or if 50% or more of the small intestine is lost.
Common causes of SBS include extensive surgical removal of sections of the intestine. In adults, Crohn’s disease, mesenteric vascular accidents (like blood clots or narrowed arteries reducing blood flow), radiation enteritis, and trauma are frequent reasons for such resections. For children, SBS results from congenital conditions like intestinal atresias, intestinal volvulus, or necrotizing enterocolitis, which cause portions of the intestine to be missing or non-functional from birth or early life.
Patients with SBS face challenges like severe malabsorption, leading to chronic diarrhea, dehydration, malnutrition, and weight loss. The inability to absorb sufficient nutrients necessitates parenteral nutrition (TPN), where a specialized liquid formula is delivered directly into the bloodstream through a central venous catheter. While TPN provides essential nutrients, long-term dependence can lead to complications such as liver disease, infections related to the catheter, gallstones, and kidney stones.
The Surgical Approach
The Bianchi procedure, also known as Longitudinal Intestinal Lengthening and Tailoring (LILT), involves a unique method to increase intestinal length. It begins by separating the two leaves of the mesentery, which is the tissue that attaches the intestine to the abdominal wall and contains its blood supply. This separation allows the surgeon to access and prepare the segment of the dilated small bowel that will be lengthened.
Once the mesentery is separated, the surgeon longitudinally divides the dilated segment of the small bowel into two halves along its mesenteric and anti-mesenteric walls. Each of these halves is then “tubulized,” meaning they are shaped into narrower tubes. These two intestinal segments are then reconnected in an end-to-end, series fashion, creating a single, longer, and narrower intestinal pathway.
The goal of this process is to increase the functional surface area available for nutrient and fluid absorption. By lengthening and narrowing the existing bowel, food transit time can be slowed, allowing more time for digestion and absorption to occur. This technique helps to optimize the remaining intestinal capacity, potentially reducing the patient’s reliance on TPN.
Patient Suitability
Deciding if a patient is suitable for the Bianchi procedure involves an evaluation by a multidisciplinary medical team. This team includes pediatric surgeons, gastroenterologists, nutritionists, and anesthesiologists. Patient selection criteria are stringent, as the procedure is considered for individuals with severe, irreversible short bowel syndrome.
Candidates demonstrate long-term dependence on total parenteral nutrition (TPN) and have not achieved sufficient nutrient absorption through other medical management strategies. The length and overall condition of the remaining small intestine are assessed to determine if there is enough viable bowel that can be lengthened. Additionally, the patient’s overall health and nutritional status are evaluated to ensure they can tolerate the demands of a surgical intervention.
Recovery and Long-Term Outlook
Following the Bianchi procedure, patients experience a period of recovery that begins with a hospital stay. The initial focus is on supporting the patient’s nutritional needs, continuing with total parenteral nutrition (TPN) while the gastrointestinal system heals. Gradually, oral feedings are reintroduced as the patient’s digestive function improves and their tolerance increases.
The long-term goals of the Bianchi procedure center on reducing or eliminating the patient’s dependence on TPN. By increasing the functional length of the small intestine, the procedure aims to improve the body’s ability to absorb nutrients and fluids from oral or enteral feedings. Studies have shown that a significant percentage of patients, ranging from 44% to 91%, have been weaned off TPN following the Bianchi procedure.
Beyond nutritional autonomy, the procedure can lead to an improved quality of life. Reduced reliance on TPN can decrease the frequency of catheter-related infections and other complications associated with long-term intravenous feeding. While survival rates for intestinal lengthening procedures are good, with recent data indicating an 89% survival rate over the last fifteen years, ongoing monitoring and nutritional support are necessary to ensure sustained improvement.