The colon as an energy salvage organ for children with short bowel syndrome

Background: The main cause of intestinal failure is short bowel syndrome (SBS). The management goal for children with SBS is to promote intestinal adaptation while preserving growth and development with the use of parenteral nutrition (PN). Objectives: This study evaluated the intestinal absorption rate in children with SBS, focusing on the role of the remnant colon. In addition, the relation between intestinal absorption rate, citrulline concentration, and small bowel length was studied. Methods: Thirty-two children with SBS on PN were included. They were divided into 3 groups according to the European Society for Clinical Nutrition and Metabolism (ESPEN) anatomical classification system: type 1 SBS (n = 9), type 2 (n = 13), and type 3 (n = 10). Intestinal absorption rate was assessed by a stool balance analysis of a 3-d collection of stools. Plasma citrulline concentrations were measured and the level of PN dependency was calculated. Results: The total energy absorption rate did not differ significantly between the 3 groups: 68% (61-79%) for type 1, 60% (40-77%) for type 2, and 60% (40-77%) for type 3 (P = 0.45). Children with type 2 or 3 SBS had significantly shorter small bowel length than children with type 1: 28 cm (19-36 cm) and 16 cm (2-29 cm), respectively, compared with 60 cm (45-78 cm) (P = 0.04). Plasma citrulline concentrations were lower in type 3 SBS but not significantly different: 15 mu mol/L (11-25 mu mol/L) in type 1, 14 mu mol/L (7-21 mu mol/L) in type 2, and 9 mu mol/L (6-14 mu mol/L) in type 3 (P = 0.141). A multivariate analysis confirmed the role of the remnant colon in providing additional energy absorption. Conclusion: This study demonstrated the importance of the colon as a salvage organ in children with SBS. Plasma citrulline concentrations should be interpreted according to the type of SBS. Efforts should focus on conservative surgery, early re-establishment of a colon in continuity, and preserving the intestinal microbiota.