Book Review

Intestinal Failure: Diagnosis, Management, and Transplantation

N Engl J Med 2008; 359:2181November 13, 2008

Article

Intestinal Failure: Diagnosis, Management, and Transplantation
Edited by Alan N. Langnas, Olivier Goulet, Eamonn M.M. Quigley, and Kelly A. Tappenden. 390 pp., illustrated. Malden, MA, Blackwell, 2008. $149.95. ISBN: 978-1-4051-4637-1

The development of intravenous nutrition that enables patients to survive for months or years, even when they are completely dependent on it, should be considered one of the major medical advances of the 20th century. Until intravenous nutrition was developed about 40 years ago, there was little hope for patients with major loss of intestinal function. Perhaps this is not surprising, since there are as many as 35 essential nutrients that we unwittingly ingest that need to be artificially introduced to the body when the gastrointestinal tract fails to work.

The gut is extremely complex. There is more lymphoid tissue associated with the gut than there is in all the rest of the body, and there are 10 times as many bacteria within the lumen as there are in all the eukaryotic cells of the body. Loss of gut function has not only physiological consequences but also profound psychological and social effects. For patients with intestinal failure to attain the best possible level of health and quality of life, many aspects of care need to be brought together.

Intestinal Failure is a comprehensive overview of the far-reaching effects of loss of the gut. It is a good update on state-of-the-art treatment of patients from infancy through adulthood, and the authors also go behind the scenes to discuss aspects of care such as the manipulation of intestinal flora, vascular access for intravenous feeding, and the treatment of patients with fabricated illness.

In the first three sections of the book, the reader is taken from a historical overview of the management of intestinal failure to our current understanding of the complexities of intestinal immunology and physiology, and then to the causes of intestinal failure. The authors of the remaining four sections cover the treatment of intestinal failure, starting with intravenous replacement of gut function, exploring the many medical approaches to the improvement of any residual gut function, and describing surgical procedures that can be used to salvage the gut. The chapters in the final section are discussions of intestinal transplantation — the course of action when all else has been tried and has failed.

The chapter on the history of intestinal failure and transplantation is one of the most informative histories I have come across. The major problems of infection, vascular access, and liver disease in patients who receive long-term treatment with intravenous nutrition are addressed. The section on intestinal transplantation is beautifully detailed. The fact that there are so many different surgical procedures, which vary in the number of abdominal organs and components of the gastrointestinal tract that are involved, illustrates the complexity of both the surgery and the underlying disease. It is exciting to see that there is now a body of experience with intestinal transplantation from living donors. The authors clearly state that a transplant is a new disease and way of life — not a cure. Although the patient is usually freed from the monotony of intravenous feeding, there are other risks. The important final chapter is a discussion of the financial cost of intestinal failure and whether intestinal transplantation is affordable.

Overall, Intestinal Failure gives insight into recent progress in the understanding of intestinal failure, covers the most important topics that the clinician working in this area will face, and leaves the reader thinking that there are still many exciting areas to be explored to provide the best possible care for the patient without a working gut. Despite major improvements in the survival of patients with severe intestinal failure, the treatment of patients with poor gut function remains an exciting and challenging area of medicine, and this book enables the reader to have a good overview and understanding of the topic.

Susan Hill, B.M., D.M.
Great Ormond Street Hospital for Children, London WC1N 3JH, United Kingdom
hills1@gosh.nhs.uk