Intestinal adaptation in short bowel syndrome without tube feeding or home parenteral nutrition: report of four consecutive cases.

Because home total parenteral nutrition (TPN) is not available to most of the Brazilian population, an alternative treatment for short bowel syndrome was evaluated. Four patients ages 40-65 y (mean: 53.75 +/- 10.59), three with mesenteric thrombosis, and one with Crohn's disease were studied. The average length of the remaining small bowel in these patients was 54.5 +/- 6.4 cm; the ileocecal valve was preserved in 3 cases. A progressive step diet was used for intestinal adaptation. Administration of pectin was started at the beginning of the special oral diet (step 1), followed by medium-chain triacylglycerols (MCTs) and complex, nonfermentable sugars (step 2); coconut oil (47% MCTs) and simple sugars (step 3); and long-chain triacylglycerols and lactose (step 4). TPN was interrupted at step 3 or 4 when the energy content of the diet reached 150% of the patient's resting energy expenditure, if serum albumin and weight were stable or increasing, and if the frequency, amount, and consistency of stools remained unchanged. Nutritional follow-up showed that patients responded well to this approach; also, patients returned to their previous professional activities. Thus, enteral formulas were not essential for gastrointestinal adaptation. Home TPN should not be indicated on the basis of strict criteria, but rather when a patient fails to adapt to a progressive, special oral diet.