Short bowel (SB) happens after an acute abdominal condition that leads to a significant loss of small bowel.

The aim of treatment in patients with short bowel is to achieve enteral autonomy (EA) and minimise complications.

Survival depends on early diagnosis and the institution of an Intestinal Rehabilitation Programme (IRP) which consist of:


  • liver-sparing parenteral nutrition (PN)

  • careful central venous feeding line management, to avoid or control sepsis and to maintain venous access sites

  • non-transplant surgery and social integration. Non transplant surgery should be regarded as a process (potentially involving more than one procedures) leading to EA. This process is better known as Autologous Gastrointestinal Reconstruction (AGIR)

The indication to non-transplant surgery is clear:

  • severe short bowel

  • neonatal/paediatric mucosal spearing procedure

  • bacterial overgrowth when on 100% PN

  • bowel dilatation

  • normal calibre bowel

  • fast transit.

The possibility of further lengthening an already lengthened bowel is a viable option providing there are no other health issues.The indication to re-lengthening are: 

  • already planned surgery as initial starting bowel’s length very poor (<5 cm)

  • bowel dilatation

  • normal calibre bowel but still on PN 12 months following the initial lengthening

  • bacterial overgrowth.

In patients with more than 40cm of residual bowel the procedure to be performed should be based on surgeons’ experience as one operation in the context of an IRP should be sufficient to achieve EA. 

In the presence of older children classified as “intestinal failure” because of poor oral intake and on a long term PN it is important to asses the potential presence of bowel dilatation. The real problem in these patients is related to the dysfunctional and dilated bowel and once it has resolved they should successfully progress to EA. 

Transplant should be used only if patients fail to adapt once AGIR cannot offer more options or liver complications or loss of venous access happen. We do believe that a stable and healthy patient who fails to adapt stands better chance to successfully go through an isolated bowel transplantation compared to a patient needing an “urgent” combined liver and small bowel transplant as a matter of life and death in poor general condition (e.g advanced liver disease, poor nutrition…).

In our experience this “patient centred” approach improves survival, quality of life for children and families  and save money (e.g. hospital stay, time on PN, need for transplantation...) and allows better selection of patients for transplantation with consequent better organs’ utilisation.  

The unit at Royal Manchester Children's Hospital under Prof. Antonino Morabito had thirty years experience in the multi-systemic approach to the management of short gut syndrome with significant improvement in our results especially in children with less than 40cm of bowel. This unit had the largest series in the UK with regards to AGIR. Prof. Antonino Morabito is now at the Meyer Children's Hospital in Florence Italy.