Staged Controlled Bowel Expansion Prior to Serial Transverse Enteroplasty in Preterm Neonates with Short Bowel Syndrome: A Safe and Feasible Strategy to Enable Intestinal Reconstruction

BACKGROUND: Preterm neonates with short bowel syndrome represent one of the most challenging populations in pediatric intestinal rehabilitation. Autologous intestinal reconstruction is frequently delayed in this group because insufficient bowel dilation precludes safe lengthening, prolonging dependence on parenteral nutrition and increasing the risk of intestinal failure-associated liver disease, sepsis, and growth failure. METHODS: We conducted a retrospective single-center cohort study of preterm neonates with short bowel syndrome managed with a standardized protocol of controlled bowel expansion (CBE) followed by serial transverse enteroplasty (STEP) between 2018 and 2025. Eligible patients had pediatric intestinal failure requiring parenteral nutrition for ≥60 consecutive days. Primary outcomes were bowel length gain and achievement of enteral autonomy. Secondary outcomes included complications and resolution of intestinal failure-associated liver disease (IFALD). RESULTS: Nine preterm neonates were included (median gestational age 27 weeks IQR, 25-28; median birth weight 880 g IQR, 820-1080; underlying aetiology predominantly necrotizing enterocolitis 78%). Baseline bowel length was a median of 33 cm (18% of expected for gestational age). During the CBE phase, bowel length increased by a median of 20 cm (IQR, 14.5-30), allowing progression to definitive STEP after a median expansion period of 27 weeks (IQR, 18.1-33). STEP provided an additional median gain of 20 cm (IQR, 14-40), with a cumulative median gain of 54.5 cm (IQR, 42-61) and a final bowel length of 61% of expected. Eight of nine patients (88%) achieved full enteral autonomy at a median of 29.3 weeks post-STEP (IQR, 24.1-52.5). IFALD resolved in all affected patients, and no mortality or post-STEP surgical complications occurred. CONCLUSIONS: In preterm neonates with short bowel syndrome, CBE was incorporated as part of a staged surgical pathway prior to STEP, during which bowel length increased. This approach was feasible and was associated with progression to STEP, with high rates of enteral autonomy observed in the cohort. . These findings suggest that CBE may serve as a preconditioning strategy to enable timely reconstruction in a population traditionally considered unsuitable for early lengthening. Prospective multicentre studies are warranted to validate these outcomes and standardize patient selection.