title: Taking a STEP back: Assessing the outcomes of multiple STEP procedures.
abstract: OBJECTIVE
  Short bowel syndrome (SBS) is a highly morbid condition primarily because of parenteral nutrition (PN)-associated complications. Bowel lengthening via serial transverse enteroplasty (STEP) has become standard of care. While initial STEPs have resulted in weaning from PN, outcomes of repeated STEPs (ReSTEPs) are not well described. We investigated outcomes of initial STEP compared to ReSTEP procedures.
  
  
  METHODS
  This retrospective review of STEPs included 17 children and a total of 24 procedures. Demographics, complications, hospital readmission rates, postoperative costs, and PN weaning were analyzed.
  
  
  RESULTS
  Neither patient-specific data nor the etiology of SBS was predictive of requiring a ReSTEP. PN weaning was more likely in the year following a first STEP (18% wean rate vs. 0% for ReSTEP, p>.05). No ReSTEP patients reached enteral autonomy. Enteral nutrition (%EN) increases were greater after first STEP compared to ReSTEP (26.0% vs. 4.7%, p=0.03). This trend was true for bowel length as well, where first STEPs resulted in a 51% increase in bowel length compared to a 20% increase after in ReSTEP (p=0.02).
  
  
  CONCLUSIONS
  ReSTEPs failed to result in significant PN weaning, with no ReSTEP patients achieving enteral autonomy during follow-up. Given its higher costs, smaller bowel length gains, and limited ability to produce enteral autonomy, surgeons should carefully consider performing ReSTEP procedures.
  
  
  METHODS
  Level III.
authors.affiliation: Division of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan; Ann Arbor, MI. Electronic address: mebarret@med.umich.edu.
authors.forename: Meredith
authors.initials: M
authors.lastname: Barrett
authors.affiliation: Division of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan; Ann Arbor, MI.
authors.forename: Farokh R
authors.initials: FR
authors.lastname: Demehri
authors.affiliation: Division of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan; Ann Arbor, MI.
authors.forename: Graham C
authors.initials: GC
authors.lastname: Ives
authors.affiliation: University of Michigan Clinical Financial Planning and Analysis Center, University of Michigan Health System; Ann Arbor, MI.
authors.forename: Kristen
authors.initials: K
authors.lastname: Schaedig
authors.affiliation: Division of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan; Ann Arbor, MI.
authors.forename: Meghan A
authors.initials: MA
authors.lastname: Arnold
authors.affiliation: Division of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan; Ann Arbor, MI.
authors.forename: Daniel H
authors.initials: DH
authors.lastname: Teitelbaum
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003131:Combined Modality Therapy; D013505:Digestive System Surgical Procedures / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007421:Intestine, Small / Q000601:surgery*; D008297:Male; D010289:Parenteral Nutrition, Total; D012086:Reoperation; D012189:Retrospective Studies; D012778:Short Bowel Syndrome / Q000601:surgery* / Q000628:therapy; D016896:Treatment Outcome
keywords: Enteral nutrition; Parenteral nutrition; Postoperative complications; STEP procedure; Short bowel syndrome