21 Dec 2012
New Delhi, India.
Just three inches of the six–metre–long small intestine remain in the body of the 23–year–old physiotherapist gang–raped here four days ago, as most of it was removed following serious infection caused by the trauma. This means that even if the "brave girl" pulls through, she will not be able to consume solid food for years.
The small intestine is actually one of the most vital parts of the human anatomy. It is where 90% of the digestion and food absorption occurs. Enzymes and bile acids break down food with all the nutrients absorbed by the inner walls of the small intestine into the blood stream. With no small intestine left, her body will have to receive nutrition directly through her vein called total parenteral nutrition (TPN).
"She won’t be able to have food through the oral route for years," said Dr K T Bhowmik of Safdarjung Hospital. Dr M C Mishra, chief of AIIMS’s trauma centre, told TOI, "Her future isn’t bright because she will have to be on TPN for months. TPN is normally given through a large central vein that goes into the heart and major vessels. The sites get infected over time and affect the liver. This is the major challenge."
Dr A S Soin, transplant surgeon at Medanta Medicity, added, "She may be able to eat after months through the oral route but that will only be for physical satisfaction. It will go out immediately through the tube put inside her for drainage. The body won’t absorb any nutrition and she will suffer from serious malnutrition. If a patient has less than 30–40 cm of intestine left, hope for recovery or having oral food is lowest. TPN will be her only hope." One option for the girl could be an intestinal transplant. "But that hasn’t been conducted successfully in India. It is commonly done in Leeds in the UK and in Toronto. But that isn’t even an option at present. It will be at least six months to a year before we can give it a thought," Dr Bhowmik said.
Dr Mishra added, "Bowel transplant is done in very few numbers even in developed countries. Also, its success rate is very low. If kidney and liver transplant has a 90% success rate, it is as low as 30%– 40% in case of a bowel transplant." The immediate concern of the Safdarjung Hospital team taking care of the victim is how to stabilize and move her out of the ICU.
"ICU is a bad place to be in as it is swarming with infection. Our immediate concern is to see whether we can stabilize her outside an ICU. Infection rates in an ICU are 40% higher than that in a ward. She has catheters, IV lines all of which are major sources of infection," Dr Bhowmik said.
He lamented, "We don’t know how long we can pull her through. She has multiple injuries, all of which are severe. All of them can be a source for fresh infections. She is under heavy antibiotic cover. At some stage, her immunity will dip." Another doctor said, "Its not like the next 72 hours are critical. It is actually the next 7–10 days that will be vital for her survival. Reconstruction work will take place months later. At present, no more surgeries are planned. The focus is to ensure she pulls through without being on ventilator."
Dr Soin also pointed to the fact that the small intestine harbours a number of immunity cells that protect us from dangerous infections. "A person can still survive without a large intestine. Without the small intestine, it can be fatal. It makes us more prone to foreign infections that can be life threatening," a doctor said.
Experts said an intestine transplant is performed when the patient is dependent on intravenous TPN, has developed infections or complications that make it increasingly difficult to administer TPN, liver failure or has a nonfunctional bowel. An intestinal transplant surgery is a last suitable option of treatment for patients with intestinal failure who develop life–threatening problems from TPN.NO INTESTINES, BUT LOTS OF GUTS
Health–wise, the victim is still in high–risk zone, but showing amazing will to live. What does she have to battle against?Her small intestine has been removed
90% of digestion and food absorption occurs in small intestine. Minus this there can be no nutrition intake through mouth. Chemical digestion with enzymes and bile acids take place here. Food is broken down into form that can be absorbed and sent to various tissues. Once broken down, nutrients are absorbed by inner walls of small intestine into blood stream
Small intestine is 22 ft long; as a person grows, length grows 30 times from 200cm in baby to over 6 metres in adult
Lack of small intestine will cause Short–Bowel Syndrome – a disorder defined by malabsorption, diarrhoea, fluid and electrolyte disturbances and malnutrition
She can get nutrition through Total Parenteral Nutrition
TPN is a way of supplying nutritional needs by bypassing digestive system. Normally given through a large central vein, TPN used when small intestine is not absorbing nutrients
TPN catheter is used only for nutrients; medications are not added to the solution. Adults need approximately 2 litres of TPN solution daily
In US, around 10,000 patients receive home–delivered TPN for Short–Bowel Syndrome
In UK, incidence of syndrome is 2 patients per million
All going well, she might have an intestinal transplant. It hasn’t been done successfully in India, although it is commonly done in Leeds (UK), Toronto (Canada) & US. With Sheila Dikshit saying, if necessary, she would be sent abroad for treatment, this is a long–shot possibility. Only after this will she go through any reconstruction surgery of her lower parts