Intestinal failure (IF) describes a clinical state in which parenteral administration of nutrition, fluids, and electrolytes is essential to maintain health. This encompasses acute alterations of intestinal function in the setting of perioperative and critical care (e.g., postoperative ileus and intestinal obstruction) and more severe and prolonged conditions often associated with severe abdominal sepsis and intestinal fistulation. IF may also occur in the chronic setting of short bowel syndrome, for which life-long parenteral nutritional support, intestinal lengthening, or transplant surgery may be appropriate.
Mild acute IF almost always settles quickly and can usually be managed simply with parenteral nutrition and fluid therapy; however, severe acute IF remains a considerable challenge associated with a high mortality. This is largely attributable to the challenge of managing severe abdominal sepsis. Early and aggressive diagnosis and management of abdominal infection by maintaining a high index of clinical suspicion, promptly applying cross-sectional imaging, and effectively controlling the source, supported by appropriate and timely antibiotic therapy and supportive critical care, are essential to a good outcome. Effective source control can be achieved via radiological or surgical means, depending on the location of the abdominal infection. Although radiological drainage is often possible and is usually preferable, surgical intervention is frequently required in the presence of extensive tissue necrosis and/or intestinal discontinuity. In such cases, exteriorization of the bowel is almost always needed. When peritoneal contamination is severe and there are concerns regarding intra-abdominal hypertension (abdominal compartment syndrome), the abdomen may need to be left open, often for prolonged periods, and allowed to heal by secondary intention (unlike in trauma surgery). The aim in all cases should be to preserve the remaining gastrointestinal tract, if possible, especially in patients with inflammatory bowel disease. Sepsis control and care of the wound or fistula sites are followed by nutritional support, usually via the parenteral route, which should be meticulous and uncomplicated.
With effective management of sepsis and nutritional support, severe acute IF may resolve right away or after reconstructive surgery performed when the patient’s condition permits. Reconstructive procedures can be complex and technically demanding, involving surgery in a hostile abdomen and reconstruction of both the gastrointestinal tract and abdominal wall. These procedures may require considerable expertise and judgement if refistulation or considerable loss of intestine (resulting in chronic intestinal failure) is to be avoided. The support of an adequately resourced multidisciplinary team for the management of patients with IF is essential if optimum outcomes are to be achieved.
