Current status of small bowel and multivisceral transplantation

Should a Stoma Be Used After Intestinal Transplant

As we all acknowledge benefits of ostomies, they can come with significant morbidity, quality of life issues, and major complications, especially during reversal procedures. In recent years, we have started to observe that similar graft and patient survival can be achieved without ostomies in certain cases. This observation and practice adopted in a few large-volume transplant centers opened a new discussion about the necessity of ostomies in intestinal transplantation. There is still more time and randomized studies will be needed to better understand and analyze the risk/benefits of "No-ostomy" approach in intestinal transplantation.

Intestinal and Multivisceral Transplantation: Indications and Surgical Techniques

Intestinal transplantation and multivisceral transplantation are technically challenging and complex procedures mainly performed on patients with irreversible and non-medically manageable end-stage intestinal failure. Increasingly, other organs besides small intestines are included in the allograft for which the terms "composite intestinal transplantation" and "multivisceral transplantation" are used. Commonly, complex vascular reconstructions are used for these procedures. Knowledge of surgical anatomy hence is essential for accurate interpretation of postoperative imaging in these patients. This article reviews the indications and most common surgical techniques for intestinal and multivisceral transplantations.

Multidrug-resistant Klebsiella Pneumoniae Infection Led to Resection of the Graft in a Small Bowel Transplant Recipient: A Case Report and Review of the Literature

BACKGROUND

Infection due to multidrug-resistant Klebsiella pneumoniae is a common cause of graft resection after small bowel transplantation. We report a failed case in which the intestinal graft was resected 18 days after the operation due to postoperative infection with multidrug-resistant K pneumoniae and a literature review of other common causes of small bowel transplantation failure have been reported.

METHODS

A female, 29 years of age, underwent partial living small bowel transplantation for short bowel syndrome. After the operation, the patient was infected with multidrug-resistant K pneumoniae, even though various anti-infective regimens were employed. It further developed into sepsis and disseminated into intravascular coagulation, leading to exfoliation and necrosis of the intestinal mucosa. Finally, the intestinal graft had to be resected to save the patient's life.

RESULTS

Multidrug-resistant K pneumoniae infection often affects the biological function of intestinal grafts and can even lead to necrosis. Other common causes of failure, including postoperative infection, rejection, post-transplantation lymphoproliferative disorder, graft-vs-host disease, surgical complications, and other related diseases, were also discussed throughout the literature review.

CONCLUSIONS

Pathogenesis due to diverse and interrelated factors makes the survival of intestinal allografts a great challenge. Therefore, only by fully understanding and mastering the common causes of surgical failure can the success rate of small bowel transplantation be effectively improved.

Donor-derived vancomycin-resistant enterococci transmission and bloodstream infection after intestinal transplantation

BACKGROUND

Transplant recipients are at high risk for infections. However, donor-recipient transmission of multidrug-resistant organisms (MDROs) remains mostly unaddressed in the protocols of pre-transplant infection and colonization screening. Vancomycin-resistant enterococci (VRE) are MDROs that colonize the gastrointestinal tract and are associated with a significant burden of disease. Besides the high mortality of invasive VRE infections, chronic colonization leads to costly isolation measures in the hospital setting. Whereas most post-transplantation VRE infections are endogenous and thus preceded by colonization of the recipient, conclusive evidence of VRE transmission via allograft in the context of intestinal transplantation is lacking.

CASE PRESENTATION

We describe a donor-derived VRE infection after intestinal transplantation including small bowel and right hemicolon. The recipient, a 54-year old male with history of mesenteric ischemia and small bowel perforation due to generalized atherosclerosis and chronic stenosis of the celiac trunk and the superior mesenteric artery, developed an intra-abdominal infection and bloodstream infection after transplantation. VRE isolates recovered from the patient as well as from the allograft prior to transplantation were analyzed via whole genome sequencing. Isolates showed to be genetically identical, thus confirming the transmission from donor to recipient.

CONCLUSIONS

This case underlines the relevance of donor-recipient VRE transmission and invasive infection in the context of intestinal transplantation, highlighting the need for preoperative MDRO screening that facilitates the prompt and effective treatment of possible infections as well as the timely establishment of contact precautions to prevent further spread.

One-year Incidence of Infection in Pediatric Intestine Transplantation

BACKGROUND

This study reports the infection rate, location of infection and pathogen causing bacterial, fungal or viral infections in intestine transplant recipients at a pediatric transplant center.

METHODS

Records from a pediatric center were reviewed for patients receiving an intestine transplant. Positive cultures and pathology reports were used to diagnose bacterial, fungal and viral infections and also to determine location and infectious agent. Risk for infection was assessed based on liver or colon inclusion, and immunosuppression induction, as part of the intestine transplant.

RESULTS

During the study period, 52 intestine transplants were performed on 46 patients. Bacterial, fungal and viral infection rates were 90%, 25% and 75%, respectively. Enterococcus spp. (non-vancomycin-resistant enterococci) were the most common pathogens and were isolated from 52% of patients. Non-vancomycin-resistant enterococci was present in 12% of transplant recipients. Candida spp. were the most common fungal pathogens (23% of patients). Respiratory viral infections were common (44%), and Cytomegalovirus infection rate was 17%. Common sites of infection were bloodstream, urinary and upper respiratory tract. Colon and liver inclusion in the transplant graft was not associated with increased risk of infection, nor was addition of rituximab to the immunosuppression induction protocol.

CONCLUSIONS

Postintestine transplant infections are ubiquitous in the pediatric population, including high rates of infection from bacterial, viral and fungal sources. Inclusion of the liver and/or colon as a component of the transplant graft did not appear to greatly impact the infectious risk. Adding rituximab to the immunosuppression induction protocol did not impact on infectious risk.

Simultaneous Serial Transverse Enteroplasty (STEP) in Size Mismatch Small Bowel Transplantations

BACKGROUND

Small bowel transplantation (SBTX) in children receiving larger grafts from adults can be challenging because of size mismatch. The aim of the present study was to assess whether a simultaneous serial transverse enteroplasty (STEP) can address the problem of size mismatch.

METHODS

Three different size ratio groups between donors and recipients were compared in a porcine model with a 14-day follow-up. The groups were size matched, size mismatched (1:3.8 weight ratio), and size mismatched + STEP (each n = 8).

RESULTS

It was technically feasible to simultaneously perform a STEP and SBTX of a mismatched intestinal segment. The postoperative clinical course was uneventful. No signs of bleeding, leakage, stenosis, or ileus were observed and the intestinal segment was well perfused at relaparotomy. Body weight decreased in all groups, but the percentage decrease was lowest in the mismatched + STEP group. Vital enterocyte masses were similar in all the groups (citrulline levels) and the nutritional status was best in the STEP group (transferrin levels, p = 0.04).

CONCLUSIONS

We have demonstrated that a simultaneous STEP and SBTX procedure is technically feasible and clinically useful in overcoming the challenges associated with size mismatched SBTX. Our short-term findings justify further investigation in a larger series to elucidate the long-term outcomes of this procedure.

Outcomes of Adult Intestinal Transplant Recipients Requiring Dialysis and Renal Transplantation

Supplemental digital content is available in the text.

Background

Data on dialysis and renal transplantation (RT) after intestinal transplantation (IT) are sparse. Whether changes in immunosuppression and surgical techniques have modified these outcomes is unknown.

Methods

Two hundred eighty-eight adult intestinal transplants performed between 1990 and 2014 at the University of Pittsburgh were analyzed for incidence, risk factors and outcomes after dialysis and RT. Cohort was divided into 3 eras based on immunosuppression and surgical technique (1990-1994, 1995-2001, and 2001-2014). Receiving RT, or dialysis for 90 days or longer was considered as end-stage renal disease (ESRD).

Results

During a median follow-up of 5.7 years, 71 (24.7%) patients required dialysis, 38 (13.2%) required long-term dialysis and 17 (6%) received RT after IT. One-, 3-, and 5-year ESRD risk was 2%, 7%, and 14%, respectively. No significant era-based differences were noted. Higher baseline creatinine (hazard ratio [HR], 3.40 per unit increase, P < 0.01) and use of liver containing grafts (HR, 2.01; P = 0.04) had an increased ESRD risk. Median patient survival after dialysis initiation was 6 months, with a 3-year survival of 21%. Any dialysis (HR, 12.74; 95% CI 8.46-19.20; P < 0.01) and ESRD (HR, 9.53; 95% CI, 5.87-15.49; P < 0.01) had higher mortality after adjusting for covariates. For renal after IT, 1- and 3-year kidney and patient survivals were 70% and 49%, respectively. All graft losses were from death with a functioning graft, primarily related to infectious complications (55%).

Conclusions

In intestinal transplant recipients, renal failure requiring dialysis or RT is high and is associated with increased mortality. Additionally, the outcomes for kidney after IT are suboptimal due to death with a functioning graft.

Comparable outcomes in intestinal retransplantation: Single-center cohort study

BACKGROUND

Graft loss in intestinal transplantation (ITx) is close to 25% in the first year and 50% at 5-year post-transplantation. Although technically and immunologically challenging, intestinal retransplantation is now the 4th most common indication for ITx.

METHODS

The aim of this study was to review and compare the outcomes of intestinal retransplantation with primary ITx, which included isolated ITx, modified multivisceral transplantation (mMVTx), and full MVTx, between 2003 and 2014 at Indiana University.

RESULTS

Of 218 ITx, 18 (8.3%) were retransplantation. Causes of graft loss were rejection(78%), pancreatitis (11%), and severe intestine dismotility (11%). MVTx (16/18, 89%) was the preferred retransplantation option. In 7 (39%) patients, graftectomy was performed between primary and intestinal retransplantation. Median interval between primary ITx and retransplantation was 421 days. Although patient and graft survival rates at 1 year, 3 years, and 5 years were comparable between primary and retransplants, the number of retransplants was limited in the follow-up after post-transplant year 3.

CONCLUSIONS

We identified that timing of retransplantation, graftectomy prior to retransplant allowing an immunosuppression free state, inclusion of the liver, and preserved renal function are important factors in the consideration of intestinal retransplantation. Immunological aspects remain challenging in the decision making and for short- and long-term outcomes.

Intestinal transplants: review of normal imaging appearance and complications

Intestinal transplant (IT) is one of the least common forms of organ transplant but is increasing both in volume of cases and number of centers performing intestinal transplants, with the busiest centers in North America and Europe. IT can be performed in isolation or as part of a multivisceral transplant (MVT). Intestinal failure either in the form of short gut syndrome or functional bowel problems is the primary indication for IT. The normal post-surgical anatomy can be variable due to both recipient anatomy in regard to amount of residual bowel and status of native vasculature as well as whether the transplant is isolated or part of a multivisceral transplant. Complications of isolated IT and IT as part of an MVT include complications shared with other types of organ transplants such as infection, rejection, post-transplant lymphoproliferative disorder and graft versus host disease. Mechanical bowel complications of the graft include bowel obstruction, stricture, leak, perforation and enterocutaneous fistula. Lastly, vascular complications of both the venous and arterial anastomoses including stricture and pseudoaneurysm occur.

The use of vascular homografts in pediatric small bowel transplantation: Single-center experience over a decade

Intestinal transplantation in children has evolved with more isolated small intestine transplants being performed compared to combined liver-intestine transplants. Consequently, surgical techniques have changed, frequently requiring the use of vascular homografts of small caliber to revascularize the isolated small intestine, the impact of which on outcomes is unknown. Among 106 pediatric intestine and multivisceral transplants performed at our center since 2003, 33 recipients of an isolated small intestine graft were included in this study. Outcome parameters were thrombotic complications, graft, and patient survival. A total of 29 of 33 (87.9%) patients required arterial and/or venous homografts from the same donor, mainly iliac or carotid artery and iliac or innominate vein, respectively (donor's median age 1.1 years [2 months to 23 years], median weight 10 kg [14.7-48.5]). Post-transplant, there were three acute arterial homograft thromboses and one venous thrombosis resulting in two peri-operative graft salvages and two graft losses. Three of four thromboses occurred in patients with primary hypercoagulable state, including the two graft losses. Overall, at a median of 4.1 years (1-10.2) from transplant, 29 of 33 (88%) patients are alive with 26 of 33 (79%) functioning grafts. The procurement of intact, size-matched donor vessels and the management of effective post-transplant anticoagulation are critical.

The optimal intestinal segment length for experimental size-mismatched intestinal transplantation: Defining the maximum length with the lowest blood flow needs in a porcine model

Transplanted Intestinal Segments (IS) must match the perfusion capacities of the recipient. This can be challenging during a size-mismatched SBTX. In this study, we defined the maximum IS length with lowest blood flow needs in a porcine model by evaluating the physiological perfusion rates of different IS lengths. Blood flow in the SMA, aorta segment four, and general circulatory parameters were monitored before and after sequential intestinal resection. IS lengths of 30 cm, 60 cm, 120 cm, and 300 cm (n = 8 each) were compared. The IS blood flow requirements increased with IS length (30 cm: 19.5 ± 3.4 mL/min; 60 cm: 16.9 ± 6.7 mL/min; 120 cm: 34.9 ± 8.5 mL/min; 300 cm: 62.9 ± 11.6 mL/min). Absolute IS blood flow (P = .004), percentage IS blood flow uptake from the SMA (P = .001), and percentage IS blood flow uptake from the aorta (P = .005) increased significantly between 60 cm and 120 cm. We concluded that 60 cm was the maximum IS length before blood flow demands significantly increased in a porcine model.

Multivisceral transplant is a viable treatment option for patients with non-resectable intra-abdominal fibromatosis

BACKGROUND

Intra-abdominal fibromatosis often involves the mesentery root which is non-resectable by conventional surgery. Multivisceral transplant (MVT), as a potential cure to non-resectable fibromatosis, has rarely been reported and the prognosis is unknown.

METHODS

Six patients who underwent MVT for intra-abdominal fibromatosis were reviewed. Clinicopathological features, immunohistochemistry for β-catenin, p53, and Ki67, and outcomes were evaluated. Appropriate data for comparative analysis were obtained from a cohort of 24 patients who underwent conventional resection for intra-abdominal fibromatosis.

RESULTS

Among six MVT patients, four had familial adenomatous polyposis (FAP). Two patients had an initial intestinal transplantation, three had multiple prior surgeries, and two had adjuvant therapy. One patient died of hemorrhagic stroke shortly after MVT, and five patients (83%) survived with a median follow-up of 64 months. The 1-year and 5-year survival rates were 67% for all five patients. Two patients had recurrences after MVT and one of them had FAP. In comparison, six of 24 patients who underwent conventional surgery had FAP; six (25%) had recurrences and three had FAP. For FAP patients; the mean recurrence time was 13 months for MVT versus 6 months for conventional surgery. Ki67 proliferative index, β-catenin, and p53 expression did not significantly correlate to recurrence.

CONCLUSIONS

Multivisceral transplant (MVT) is a viable option for patients who have non-resectable intra-abdominal fibromatosis with promising surviving rates, although recurrence still occurs. Surgical margin, Ki67 proliferative index, β-catenin, and p53 expression are not predicative for recurrence of fibromatosis.

Mycophenolate mofetil toxicity mimicking acute cellular rejection in a small intestinal transplant

Mycophenolate mofetil (MMF) is an important medication used for maintenance immunosuppression in solid organ transplants. A common gastrointestinal (GI) side effect of MMF is enterocolitis, which has been associated with multiple histological features. There is little data in the literature describing the histological effects of MMF in small intestinal transplant (SIT) recipients. We present a case of MMF toxicity in a SIT recipient, with histological changes in the donor ileum mimicking persistent acute cellular rejection (ACR). Concurrent biopsies of the patient’s native colon showed similar changes to those from the donor small bowel, suggesting a non-graft specific process, raising suspicion for MMF toxicity. The MMF was discontinued and complete resolution of these changes occurred over three weeks. MMF toxicity should therefore be considered as a differential diagnosis for ACR and graft-versus-host disease in SITs.

Adult-to-adult living donor liver transplantation: Operative techniques to optimize the recipient's outcome

Adult-to-adult living donor liver transplantation (LDLT) is widely accepted today with good outcomes and safety reported worldwide for both donor and recipient. Nonetheless, it remained a highly demanding technical and complex surgery if undertaken. The last two decades have seen an increased in adult-to-adult LDLT following our first report of right lobe LDLT in overcoming graft size limitation in adults. In this article, we discussed the operative techniques and challenges of adult right lobe LDLT incorporating the middle hepatic vein, which is practiced in our center for the recipient operation. The various issues and challenges faced by the transplant surgeon in ensuring good recipient outcome are explored and discussed here as well. Hence, it is important to understand that a successful recipient operation is dependent of multifactorial events starting at the preoperative stage of planning, understanding the intraoperative technical challenges and the physiology of flow modulation that goes hand-in-hand with the operation. Therefore, one needs to arm oneself with all the possible knowledge in overcoming these technical challenges and the ability to be flexible and adaptable during LDLT by tailoring the needs of each patient individually.

Intestinal Failure: Adaptation, Rehabilitation, and Transplantation

Intestinal failure (IF) is a state in which the nutritional demands are not met by the gastrointestinal absorptive surface. A majority of IF cases are associated with short-bowel syndrome, which is a result of malabsorption after significant intestinal resection for numerous reasons, some of which include Crohn's disease, vascular thrombosis, and radiation enteritis. IF can also be caused by obstruction, dysmotility, and congenital defects. Recognition and management of IF can be challenging, given the complex nature of this condition. This review discusses the management of IF with a focus on intestinal rehabilitation, parenteral nutrition, and transplantation.

Reconstruction of Large Abdominal Wall Defects Using Neurotized Vascular Composite Allografts

BACKGROUND

Abdominal wall vascularized composite allotransplantation is the second most common form of vascularized composite allotransplantation. Sensory and functional recovery are expected in other forms but have never been demonstrated in abdominal wall vascularized composite allotransplantation. The authors hypothesize that coaptation of two thoracolumbar nerves will result in reinnervation of the alloflap and maintenance of the muscle component.

METHODS

Adult, male, 10-week-old Brown Norway and Lewis rats were used for experiments. The rat donor's common iliac vessels were anastomosed to the recipient's femoral vessels. Intercostal nerves T10/L1 were coapted. Four groups (n = 5 per group) were included for study: group 1, Lewis, intercostal nerves cut, not repaired; group 2, Lewis intercostal nerves cut, T10/L1 repaired; group 3, allogeneic Brown Norway-to-Lewis abdominal wall vascularized composite allotransplantation, T10/L1 repaired; and group 4, syngeneic Lewis-to-Lewis abdominal wall vascularized composite allotransplantation, T10/L1 repaired. Animals were killed on postoperative day 60. Nerve regeneration was assessed using muscle weight analysis, myofibril cross-sectional area, nerve histomorphometry, and neuromuscular junction percentage reinnervation.

RESULTS

Groups 2, 3, and 4 maintained a significantly greater percentage of postharvest weight compared with group 1 (p < 0.05). Group 1 had significantly decreased myofibril cross-sectional area compared with controls (p < 0.05). There was no significant difference in myofibril cross-sectional area in groups 2 through 4 compared with controls (p > 0.05). Group 1 had significantly decreased percentage reinnervation of the alloflap compared with controls (p < 0.05). There was no significant difference when comparing group 2 through 4 with internal, contralateral controls (p > 0.05).

CONCLUSION

In a murine model for abdominal wall vascularized composite allotransplantation, coaptation of T10/L1 will allow for reinnervation of the alloflap and maintenance of the muscle component.

Intestinal and multivisceral transplantation

Intestinal transplantation has shown exceptional growth over the past 10 years. At the end of the 1990’s, intestinal transplantation moved out of the experimental realm to become a routine practice in treating patients with severe complications related to total parenteral nutrition and intestinal failure. In the last years, several centers reported an increasing improvement in survival outcomes (about 80%), during the first 12 months after surgery, but long-term survival is still a challenge. Several advances led to clinical application of transplants. Immunosuppression involved in intestinal and multivisceral transplantation was the biggest gain for this procedure in the past decade due to tacrolimus, and new inducing drugs, mono- and polyclonal anti-lymphocyte antibodies. Despite the advancement of rigid immunosuppression protocols, rejection is still very frequent in the first 12 months, and can result in long-term graft loss. The future of intestinal transplantation and multivisceral transplantation appears promising. The major challenge is early recognition of acute rejection in order to prevent graft loss, opportunistic infections associated to complications, post-transplant lymphoproliferative disease and graft versus host disease; and consequently, improve results in the long run.

The Surgical Approach to Short Bowel Syndrome - Autologous Reconstruction versus Transplantation

BACKGROUND

Short bowel syndrome (SBS) is a state of malabsorption resulting from massive small bowel resection leading to parenteral nutrition (PN) dependency. Considerable advances have been achieved in the medical and surgical management of SBS over the last few decades.

METHODS

This review discusses in detail the surgical approach to SBS.

RESULTS

Widespread use of PN enables long-term survival in patients with intestinal failure but at the cost of PN-associated life-threatening complications including catheter-associated blood stream infection, venous thrombosis, and liver disease. The goal of management of intestinal failure due to SBS is to enable enteral autonomy and wean PN by means of a multi-disciplinary approach. Availability of modified enteral feeding formulas have simplified nutrition supplementation in SBS patients. Similarly, advances in the medical field have made medications like growth hormone and glucagon-like peptide (GLP2) available to improve water and nutrient absorption as well as to enable achieving enteral autonomy. Autologous gastrointestinal reconstruction (AGIR) includes various techniques which manipulate the bowel surgically to facilitate the bowel adaptation process and restoration of enteral nutrition. Ultimately, intestinal transplantation can serve as the last option for the cure of intestinal failure when selectively applied.

CONCLUSION

SBS continues to be a challenging medical problem. Best patient outcomes can be achieved through an individualized plan, using various AGIR techniques to complement each other, and intestinal transplantation as a last resort for cure. Maximum benefit and improved outcomes can be achieved by caring for SBS patients at highly specialized intestinal rehabilitation centers.

The friendly incidental portal vein thrombus in liver transplantation

Improved outcomes have been shown in liver transplantation (LT) with portal vein thrombosis (PVT). However, PVT is still discovered incidentally during surgery despite careful preoperative imaging. Data are limited comparing the outcomes of incidental PVT with PVT diagnosed via preoperative imaging before LT. This study aims to compare the overall outcomes of patients with PVT. From 2008 to 2012, 369 patients had LT, and 58 patients with PVT were identified. They were divided into those with non-PVT (group 0; n = 311), preoperatively identified PVT (group 1; n = 28), and incidental PVT (group 2; n = 30). The demographics, characteristics, preoperative assessment, and postoperative outcomes were compared. A survival analysis was also performed. Baseline characteristics and preoperative evaluations of all 3 groups were comparable (P > 0.05) except for Model for End-Stage Liver Disease score, tumor status, platelet levels, and serum bilirubin. A multivariate analysis only showed a high serum bilirubin level to be a predictor of PVT (P = 0.004; odds ratio, 3.395; 95% confidence interval, 1.467-7.861). Postoperative outcomes were also comparable (P > 0.05). Compared to group 2, group 1 had more patients with a Yerdel classification of 3 or 4 with more extensive surgical intervention required (P = 0.02). The survival analysis in all 3 groups was comparable with 5-year survival rate of 87.4%, 84.6%, and 91.8% in group 0, 1, and 2, respectively (P = 0.66). In conclusion, recipients with PVT undergoing LT can have similar outcomes as the non-PVT patients even if PVTs were discovered incidentally. Discovery of incidental PVT only requires thrombectomy with no substantial change of treatment strategy, and the outcome is not adversely affected because most incidental PVTs are of a lower Yerdel grade. Preoperative imaging is useful to identify those with a higher Yerdel grade to allow planning of surgical strategy during transplantation.

In vitro evaluation of bi-layer silk fibroin scaffolds for gastrointestinal tissue engineering

Silk fibroin scaffolds were investigated for their ability to support attachment, proliferation, and differentiation of human gastrointestinal epithelial and smooth muscle cell lines in order to ascertain their potential for tissue engineering. A bi-layer silk fibroin matrix composed of a porous silk fibroin foam annealed to a homogeneous silk fibroin film was evaluated in parallel with small intestinal submucosa scaffolds. AlamarBlue analysis revealed that silk fibroin scaffolds supported significantly higher levels of small intestinal smooth muscle cell, colon smooth muscle cell, and esophageal smooth muscle cell attachment in comparison to small intestinal submucosa. Following 7 days of culture, relative numbers of each smooth muscle cell population maintained on both scaffold groups were significantly elevated over respective 1-day levels—indicative of cell proliferation. Real-time reverse transcription polymerase chain reaction and immunohistochemical analyses demonstrated that both silk fibroin and small intestinal submucosa scaffolds were permissive for contractile differentiation of small intestinal smooth muscle cell, colon smooth muscle cell, esophageal smooth muscle cell as determined by significant upregulation of α-smooth muscle actin and SM22α messenger RNA and protein expression levels following transforming growth factor-β1 stimulation. AlamarBlue analysis demonstrated that both matrix groups supported similar degrees of attachment and proliferation of gastrointestinal epithelial cell lines including colonic T84 cells and esophageal epithelial cells. Following 14 days of culture on both matrices, spontaneous differentiation of T84 cells toward an enterocyte lineage was confirmed by expression of brush border enzymes, lactase, and maltase, as determined by real-time reverse transcription polymerase chain reaction and immunohistochemical analyses. In contrast to small intestinal submucosa scaffolds, silk fibroin scaffolds supported spontaneous differentiation of esophageal epithelial cells toward a suprabasal cell lineage as indicated by significant upregulation of cytokeratin 4 and cytokeratin 13 messenger RNA transcript levels. In addition, esophageal epithelial cells maintained on silk fibroin scaffolds also produced significantly higher involucrin messenger RNA transcript levels in comparison to small intestinal submucosa counterparts, indicating an increased propensity for superficial, squamous cell specification. Collectively, these data provide evidence for the potential of silk fibroin scaffolds for gastrointestinal tissue engineering applications.

A new rat model for orthotopic abdominal wall allotransplantation

Background:

Abdominal wall, one of the most commonly transplanted composite tissues, is less researched and lacking animal models. Its clinical necessities were emphasized in multiple case series to reconstruct large abdominal defects. Previous animal models have only studied components of the abdominal wall transplant. We describe findings from a new model that more likely reflect clinical transplantation.

Methods:

Full-thickness hemiabdominal wall flap was procured from Brown Norway (BN) rats and transplanted to an orthotopic defect on Lewis rats. Three groups were studied: group 1: Lewis to Lewis syngeneic; group 2: BN to Lewis control; and group 3: BN to Lewis with postoperative cyclosporine. Vascular imaging and cross vessel section were performed along with full-thickness abdominal wall. Immune cell profiling with flow cytometry at different time points was studied in all groups.

Results:

Syngeneic group had no rejection. Control group consistently showed rejection around postoperative day 6. With cyclosporine treatment, however, transplant and recipient tissue integration was observed. Flow cytometry revealed that innate immunity is responsible for the initial inflammatory events following abdominal wall engraftment. Adaptive immunity cells, specifically interferon-γ-producing T helper (Th) 1 and interleukin-17-producing Th17 cells, dramatically and positively correlate with rejection progression of abdominal wall transplants.

Conclusions:

Technical, histological, and immunological aspects of a new rat model are described. These results give clues to what occurs in human abdominal wall transplantation. In addition, Th1, a proinflammatory cell, was found to be a potential biomarker for allograft rejection.

Small bowel transplantation

BACKGROUND

Small bowel transplantation evolution, because of its complexity, was slower than other solid organs. Several advances have enabled its clinical application.

AIM

To review intestinal transplantation evolution and its current status.

METHOD

Search in MEDLINE and ScIELO literature. The terms used as descriptors were: intestinal failure, intestinal transplantation, small bowel transplantation, multivisceral transplantation. Were analyzed data on historical evolution, centers experience, indications, types of grafts, selection and organ procurement, postoperative management, complications and results.

CONCLUSION

Despite a slower evolution, intestinal transplantation is currently the standard therapy for patients with intestinal failure and life-threatening parenteral nutrition complications. It involves some modalities: small bowel transplantation, liver-intestinal transplantation, multivisceral transplantation and modified multivisceral transplantation. Currently, survival rate is similar to other solid organs. Most of the patients become free of parenteral nutrition.

Multivisceral transplantation: where do we stand?

Intestinal transplantation is the definitive therapy for patients with irreversible intestinal failure and can be combined with transplantation of other abdominal organs, such as stomach, spleen, and pancreas with or without liver. There is an increasing trend in the volume of intestinal and multivisceral transplantation in the past few decades and there is also increasing trend in patient and graft survival primarily due to improved patient selection, advances in immunosuppression, and improved perioperative management. This review summarizes the various key elements in patient selection, types of grafts, and updates in the perioperative management involved in multivisceral transplantation.

Social circumstances and medical complications in children with intestinal failure

Although most children discharged on home parenteral nutrition (HPN) will achieve enteral autonomy, some remain parenteral nutrition dependent; those who develop life-threatening complications may undergo small bowel transplantation (SBTx). The aim of this study was to investigate the relationship between social circumstances, compliance and complications.

SUBJECTS AND METHODS

An observational study in 2008-2012 on 64 children (34 HPN, 30 SBTx) from three units (two regional gastroenterology; one transplant). Social circumstances were assessed routinely as part of discharge planning; adherence by families to home care management was scored, and episodes of catheter-related blood stream infection and graft rejection were recorded for 2 years and related to compliance and social circumstances.

RESULTS

A quarter of families had a disadvantaged parent: non-English speaking (n=11), unable to read (n=5), physical disability (n=3), mental health problems disclosed (n=10); 20% children were cared for by a lone parent. Discharge home was delayed by social factors (n=9) and need for rehousing (n=17, 27%). 17/34 (50%) of HPN and 12/30 (40%) of transplant families were assessed as fully adherent. 10 families were assessed as non-adherent, eight were subject to child protection review and care was taken over by another family member (n=3) or foster parents (n=2). The risk of catheter-related blood stream infection was increased by parental disadvantage and age <3 years (p<0.05). Poor compliance was associated with complications in HPN and SBTx recipients.

CONCLUSIONS

Children receiving complex home care may be socially isolated and measures to support improved compliance such as increased community support, social care involvement and respite care may improve outcomes.

Neurologic complications of pancreas and small bowel transplantation

In the past decade, substantial improvements in patient and graft survival for pancreas and small bowel transplants have been achieved. Despite this progress, many patients still develop neurologic complications in the course of their illness. Small bowel transplants produce more neurologic complications because of the complex metabolic environment in which the procedure is performed and because of the intense immune suppression necessitated by the greater immunogenicity of the intestinal mucosa. Pancreas transplants stabilize and/or improve the signs and symptoms of diabetic neuropathy over time. Because transplantation of the pancreas is often coupled with a kidney transplant and small intestine with liver, neurologic complications in these patients sometimes reflect problems involving the organ partner or both organs. The spectrum of neurologic complications for pancreas and small bowel transplant recipients is similar to other organ transplants but their frequency varies depending on the type of transplant performed.

Intravenous administration of tetramethylpyrazine reduces intestinal ischemia-reperfusion injury in rats

Intestinal ischemia-reperfusion injury (IIRI) is a life-threatening condition requiring prompt medical intervention. Tetramethylpyrazine (TMP) is a biologically active alkaloid isolated from Ligusticum wallichii. Previously, it was shown that TMP causes vasodilatation and inhibition of platelet aggregation as well as exhibits significant antioxidant effects. Therefore, the aim of the present study was to evaluate possible therapeutic effects of TMP in the prevention of IIRI. Wistar rats (n = 80) were randomly divided into eight experimental groups and subjected to a 1 h occlusion of cranial mesenteric artery followed by 0, 1, 12, and 24 h period of reperfusion. Thirty minutes before the IIRI animals received either TMP (30 mg/kg, i.v.) or identical volume of saline. In addition, a control group of 10 animals was not exposed to IIRI. Intestine morphology was evaluated by using histopathological injury index examination (HII), goblet and Paneth cells quantification as well as by applying immunofluorescent methods such as InSitu TUNEL and caspase-3 positivity assessment. Here we showed that preconditioning with TMP prior IIRI decreases the grade of injury. Significant reduction of HII was detected in TMP pretreated groups after 0, 1, and 12 h of reperfusion where injury reduction up to 75% was found. Lower histopathological damage in preconditioned groups was accompanied with increased number of secretory epithelial cells and decreased number of apoptotic cells. These results demonstrate the protective effect of TMP on the small intestine mucosa, suggesting administration of TMP as a molecule for pharmacological intervention against IIRI.

Cocoon formation in patients with midgut neuroendocrine tumors: a rare and unrecognized final pathway

OBJECTIVES

Neuroendocrine tumors (NETs) are relatively rare with an indolent nature. As a result, treatment is often delayed and passive. The most commonly recognized disease progression leading to death is from the sequelae of bowel obstruction, ischemia, or liver failure secondary to liver metastasis. We recently recognized a rare cocoon-like formation in patients with metastatic gastroenteropancreatic NETs and hypothesize that this may be a distinct, final pathway for these patients.

METHODS

Ten patients with stage IV gastroenteropancreatic NETs, seen at our center between October 2008 and November 2011, who developed a cocoon were identified. Patient's charts, operative reports, pathology, and tumor markers were reviewed.

RESULTS

No discernable predictors were identified as precursors to this condition. One patient survived 13 months after cocoon diagnosis, and the remaining 9 patients were all deceased within 5 months. Surgical treatment was attempted in 6 patients and was only partially successful in 1 patient who had the earliest stage of cocoon formation (type 1).

CONCLUSIONS

Cocoon-like formations in patients with stage IV gastroenteropancreatic NETs is rare and may be a terminal disease progression that has not been previously recognized. The best treatment option remains unknown. Surgical treatment is not advisable, with the exception of type 1 abdominal cocoons.

A radiologist's guide to small bowel and multivisceral transplantation

This review will describe the indications for the various small bowel containing transplants. The importance of early referral will be highlighted. Radiologists play a central role in assessing these complex patients prior to transplantation. Furthermore, in the postoperative period, radiologists play an important part in diagnosing and treating complications.

Cutaneous graft versus host disease in pediatric multivisceral transplantation

Multivisceral transplantation (MvTx) is the concurrent transplantation of the stomach, pancreaticoduodenal complex, and intestine, with or without the liver. Its use is increasing worldwide as it has been considered as a therapy for patients with functional disturbance of several organs. Graft-versus-host disease (GvHD) has been a relevant clinical problem in MvTx ever since the procedure was first performed, but little has been reported about its specific cutaneous features. Our study included all pediatric patients with clinical and histopathologic evidence of cutaneous GvHD who received MvTx between October 1999 and December 2010 in University Hospital La Paz. Seventeen children underwent MvTx at our center during this period of time. Five patients developed cutaneous GvHD (29.4%). The median onset was 45.2 days after transplantation. Acute cutaneous GvHD, consisting of symmetrical maculopapular exanthema with prominent acral erythema and accentuated lesions on the face and pinnae, was clinically suspected and pathologically confirmed in four patients (80%). Three children (60%) experienced disease progression to a formation and a positive Nikolsky sign. Only one girl (20%) showed lichenoid GvHD. The first therapeutic approach was steroids and tacrolimus adjustment; many other drugs were used in refractory cases. Three of the five patients (60%) died with concomitant GvHD, the immediate cause of death being another comorbid disease. Knowledge of the features of cutaneous GvHD in MvTx allows clinicians early recognition and prompt therapeutic intervention that may prevent progression to higher-grade disease and improve outcomes for these patients.

Multivisceral transplantation: expanding indications and improving outcomes

INTRODUCTION

Multivisceral transplantation includes the simultaneous transplantation of multiple abdominal viscera including the stomach, duodenum, pancreas, and small intestine, with (multivisceral transplant, MVT) or without the liver (modified MVT, MMVT). This study reviews the changing indications and outcomes for this procedure over a 7-year period at a university medical center.

METHODS

This study is a retrospective case review of MVTs performed between 2004 and 2010 at a single center. All cases were either MVT or MMVT and included a simultaneous kidney transplant, if indicated. Graft failure was defined as loss of the graft or complete loss of function. Graft function was monitored by clinical function, laboratory values, and serial endoscopy with biopsy.

RESULTS

During the study period, 95 patients received 100 transplants including 84 MVT and 16 MMVT. There were 19 patients who received a simultaneous kidney graft. There were 24 pediatric and 76 adult recipients (range 7 months to 66 years). Indications included intestinal failure alone, intestinal failure with cirrhosis, complete portal mesenteric thrombosis, slow-growing central abdominal tumors, intestinal pseudoobstruction, and frozen abdomen. All patients received antibody-based induction immunosuppression with calcineurin inhibitor-based maintenance immunosuppression. At a median mortality adjusted follow-up of 25 months, 1- and 3-year patient survival is 72 % and 57 %. There was a learning curve with this complex procedure resulting in a 48 % patient survival during the period from 2004 to 2007, followed by a 70 % patient survival during the period from 2008 to 2010. Post-transplant complications included rejection (50 % MMVT and 17 % MVT), infection (>90 % first year), graft versus host disease (13 %), and post-transplant lymphoproliferative disorder (5 %).

CONCLUSION

Indications for MVT and MMVT have broadened to include patients with terminal conditions not amenable to other medical therapies such as slow-growing tumors of the mesenteric root, complete portomesenteric thrombosis, and abdominal catastrophes/frozen abdomen. Outcomes have improved over time with many patients returning to full functional status and enjoying long-term survival.

Trombose de veia porta no transplante hepático

INTRODUÇÃO: A trombose de veia porta foi considerada contraindicação ao transplante de fígado no passado em razão da elevada morbi-mortalidade. Diversos avanços permitiram melhora dos resultados. OBJETIVO: Revisão dos avanços e das estratégias cirúrgicas utilizadas para realização do transplante de fígado na vigência de trombose de veia porta. MÉTODO: Revisão da literatura nas bases de dados Medline, Scielo, Lilacs cruzando os descritores: portal vein thrombosis, liver transplantation, vascular complications, jump graft, graft failure, multivisceral transplant. Foram estudados a epidemiologia, fatores de risco, classificação, diagnóstico, estratégias cirúrgicas e resultados. CONCLUSÃO: A trombose de veia porta deixou de ser contraindicação para o transplante hepático. O cirurgião dispõe atualmente de uma série de estratégias para realização do transplante, variando conforme o grau da trombose. Apesar de implicar em maior morbidade e taxas de re-trombose, os resultados do transplante na presença de trombose portal são semelhantes aos observados nas séries habituais.

Post-transplant critical care outcomes for pediatric multivisceral and intestinal transplant patients

This study reviews the post-operative management of pediatric intestinal transplant patients at a single center with reporting of standard PICU benchmarks for quality of care. It is a retrospective, descriptive, chart review describing our institution's experience between 2006 and 2010. Twenty patients were included. Median age at transplant was 1.6 yr. Median length of PICU stay was 12 days. Median ventilation time was two days. Median time for continuous sedation infusion was two days, with median continuous pain medication infusion of three days. All patients were placed on parental nutrition and started on enteral feedings between days 3 and 4. Forty percent of patients required hemodynamic support. Only 35% of patients required insulin therapy. Diuretics were frequently used in this patient population. There were no episodes of early rejection. The survival rate to PICU discharge was 95%. Our institution's experience over the past four yr has been very successful with a short duration of mechanical ventilation, limited use of pain and sedation drips, early initiation of enteral feedings, minimal hemodynamic support, and a low mortality rate to PICU discharge despite a preponderance of complex MVTx recipients.

Small-Bowel Allograft Biopsies in the Management of Small-Intestinal and Multivisceral Transplant Recipients: Histopathologic Review and Clinical Correlations

Context.—Intestinal transplant has become a standard treatment option in the management of patients with irreversible intestinal failure. The histologic evaluation of small-bowel allograft biopsy specimens plays a central role in assessing the integrity of the graft. It is essential for the management of acute cellular and chronic rejection; detection of infections, particularly with respect to specific viruses (cytomegalovirus, adenovirus, Epstein-Barr virus); and immunosuppression-related lymphoproliferative disease.

Objective.—To provide a comprehensive review of the literature and illustrate key histologic findings in small-bowel biopsy specimen evaluation of patients with small-bowel or multivisceral transplants.

Data Sources.—Literature review using PubMed (US National Library of Medicine) and data obtained from national and international transplant registries in addition to case material at Columbia University, Presbyterian Hospital, and Mount Sinai Medical Center, New York, New York.

Conclusions.—Key to the success of small-bowel transplantation and multivisceral transplantation are the close monitoring and appropriate clinical management of patients in the posttransplant period, requiring coordinated input from all members of the transplant team with the integration of clinical, laboratory, and histopathologic parameters.

Nonsurgical care of intestinal and multivisceral transplant recipients: a review for the intensivist

Intestinal and multivisceral transplantation has evolved from an experimental procedure to the treatment of choice for patients with irreversible intestinal failure and serious complications related to long-term parenteral nutrition. Increased numbers of transplant recipients and improved survival rates have led to an increased prevalence of this patient population in intensive care units. Management of intestinal and multivisceral transplant recipients is uniquely challenging because of complications arising from the high incidence of transplant rejection and its treatment. Long-term comorbidities, such as diabetes, hypertension, chronic kidney failure, and neurological sequelae, also develop in this patient population as survival improves. This article is intended for intensivists who provide care to critically ill recipients of intestinal and multivisceral transplants. As perioperative care of intestinal/multivisceral transplant recipients has been described elsewhere, this review focuses on common nonsurgical complications with which one should be familiar in order to provide optimal care. The article is both a review of the current literature on multivisceral and isolated intestinal transplantation as well as a reflection of our own experience at the University of Miami.

Chronic intestinal failure in children

BACKGROUND

Chronic intestinal failure (CIF) in childhood is caused by congenital malformations and inflammatory diseases of the gut. Its reported prevalence is 13.7 per million population. Long-term home parenteral nutrition has dramatically improved the life expectancy and quality of life of children with CIF. The affected children are now treated with parenteral nutrition at home as soon as their medical state and family circumstances allow.

METHODS

The authors present data from a patient registry and review publications retrieved by a selective literature search.

RESULTS AND CONCLUSION

Children with CIF can now be expected to survive beyond adolescence, at the very least, and enjoy good quality of life. This goal can only be achieved if nutritional therapy is carried out safely and the affected children's development is closely monitored by an interdisciplinary team that consists of primary care physicians/family doctors, neonatologists, pediatric gastroenterologists, and pediatric surgeons. Moreover, the prevention, early detection, and appropriate treatment of complications such as infection, liver disease, renal dysfunction, and disturbances of bone metabolism is of vital importance. The patients' families must be supported by specially qualified ambulatory nurses and social workers. Treatment with parenteral, enteral, and oral nutrition and surgery enables most infants with CIF to meet all their nutritional needs orally by the time they start going to school. For children who suffer from intractable complications, intestinal transplantation provides a real and increasing chance of survival.

Central venous thrombosis and perioperative vascular access in adult intestinal transplantation

BACKGROUND

Venous access is crucial in intestinal transplantation, but a thrombosed venous system may prevent the use of central veins of the upper body. The incidence of venous thrombosis and the necessity to perform alternative vascular access (AVA) in intestinal transplant recipients have not been fully investigated.

METHODS

Records of adult patients who underwent intestinal transplantation between January 1, 2001, and December 31, 2009, were reviewed. Contrast venography was performed as pre-transplantation screening. Vascular accesses at the transplantation were categorized as I (percutaneous line via the upper body veins), II (percutaneous line via the lower body veins), and III (vascular accesses secured surgically, with interventional radiology, or using non-venous sites). Categories II and III were defined as AVA. Risk factors for central venous thrombosis and those for requiring AVA were analysed, respectively.

RESULTS

Among 173 patients, central venous obstruction or stenosis (<50% of normal diameter) was found in 82% (141 patients). AVA was required in 4.6% (eight patients: four in each category II and III). Large-bore infusion lines were placed via the femoral arteries in all category III patients without complications. Existing inferior vena cava filter and hypercoagulable states were identified as the risk factors for the use of AVA, but not for central venous thrombosis. Outcomes of patients who underwent AVA were similar to those of patients without AVA.

CONCLUSIONS

The majority of adult patients undergoing intestinal transplantation had at least one central venous stenosis or obstruction. The recipient outcomes were comparable when either standard vascular access or AVA was used for transplantation.

Use of an omega-3 fatty acid-based emulsion in the treatment of parenteral nutrition-induced cholestasis in patients with microvillous inclusion disease

Microvillous inclusion disease is a congenital intestinal epithelial cell disorder leading to lifelong intestinal failure. In this report, we discuss the use of a fish oil-based lipid emulsion in the treatment of 3 patients with microvillous inclusion disease who developed parenteral nutrition-associated liver disease.

Six-month incidence of bloodstream infections in intestinal transplant patients

BACKGROUND

Intestinal transplantation has emerged as an established treatment for life-threatening intestinal failure. The most common complication and cause of death is infection. Risk of infection is highest during the first 6 months, as a consequence of maximal immunosuppression, greater than that required for any other organ allograft.

METHODS

We performed a retrospective chart review of all (56) adult and pediatric (<18 years) small bowel transplant patients at our institution between November 2003 and July 2007, and analyzed the 6-month post-transplant incidence of bloodstream infections (BSIs). We evaluated multiple risk factors, including inclusion of a colon or liver, total bilirubin >5, surgical complications, and acute rejection.

RESULTS

A BSI developed in 34 of the 56 patients, with a total of 85 BSI episodes. Of these BSI episodes, 65.9% were due to gram-positive organisms, 34.1% gram-negative organisms, and 2.4% due to fungi. The most common isolates were Enterococcus species, Enterobacter species, Klebsiella species, and coagulase-negative staphylococci. Inclusion of the liver and/or a preoperative bilirubin >5 mg/dL appeared to increase the incidence of BSI (P = 0.0483 and 0.0005, respectively). Acute rejection and colonic inclusion did not appear to affect the incidence of BSI (P = 0.9419 and 0.8248, respectively). The BSI incidence was higher in children (P = 0.0058).

CONCLUSIONS

BSIs are a common complication of intestinal transplantation. Risk factors include age <18, inclusion of the liver, and pre-transplant bilirubin >5. Acute rejection and colon inclusion do not appear to be associated with increased BSI risk.

Management of enterocutaneous fistulas

Management of enterocutaneous fistulas (ECFs) involves (1) recognition and stabilization, (2) anatomic definition and decision, and (3) definitive operation. Phase 1 encompasses correction of fluid and electrolyte imbalance, skin protection, and nutritional support. Abdominal imaging defines the anatomy of the fistula in phase 2. ECFs that do not heal spontaneously require segmental resection of the bowel segment communicating with the fistula and restoration of intestinal continuity in phase 3. The enteroatmospheric fistula (EAF) is a malevolent condition requiring prolonged wound care and nutritional support. Complex abdominal wall reconstruction immediately following fistula resection is necessary for all EAFs.

Psychiatric issues in pediatric organ transplantation

Solid organ transplantation has become the first line of treatment for a growing number of life-threatening pediatric illnesses. With improved survival, research into the long-term outcome of transplant recipients has become important to clinicians. Adherence to medical instructions remains a challenge, particularly in the adolescent population. New immunosuppressant approaches promise to expand organ transplantation in additional directions. Extension of transplantation into replacement of organs such as faces and hands raises complex ethical issues.

Flow through a mechanical distraction enterogenesis device: a pilot test

BACKGROUND

We tested the coupling portion of a prototype intraluminal distraction enterogenesis device to allow flow-through of simulated enteric contents (SEC) in both pig and human jejunum.

MATERIALS AND METHODS

SEC was made using 80% corn syrup. Ten-cm pig and human intestinal segments had a spoke-shaped 2.2 cm coupling adaptor sutured in place, intraluminally. The adaptor had a flow-through area of 33.6 mm(2). SEC was pumped into the proximal part of the intestinal segment at 0.083 mL/s. The times to first passage of SEC through the coupler (first drop), 10 mL, and 20 mL of SEC eluted from the distal end were recorded.

RESULTS

Mean time to first drop elution was 155 ± 38 s with pig, and 149 ± 22 s with human bowel (P = 0.8). This corresponded to a hydrostatic pressure of 37.5 mmHg before the initial drop passed through. Mean flow rates were 0.094 mL/s in pig bowel and 0.084 mL/s in human bowel (P = 0.09). To account for occlusion from luminal debris, a 75% occlusion of coupler holes was studied in the smaller pig bowel to investigate if reductions in flow-through area could be tolerated. Mean time to first drop increased slightly to 171 ± 15 s, but the elution rate stayed the same (P = 0.5).

CONCLUSIONS

After a physiologic level of initial pressure buildup allowing the first drop of SEC to pass the coupling adaptor, our prototype intestinal coupling adaptor did not obstruct flow-through of SEC, even after a 75% decrease in flow-through area. This type of attachment represents a viable approach to placing a device in-continuity without obstructing flow of enteric contents.

Proteomic analysis of the intestinal adaptation response reveals altered expression of fatty acid binding proteins following massive small bowel resection

Intestinal adaptation in response to the loss of the small intestine is essential to restore enteral autonomy in patients who have undergone massive small bowel resection (MSBR). In a proportion of patients, intestinal function is not restored, resulting in chronic intestinal failure (IF). Early referral of such patients for transplant provides the best prognosis; however, the molecular mechanisms underlying intestinal adaptation remain elusive and there is currently no convenient marker to predict whether patients will develop IF. We have investigated the adaptation response in a well-characterized porcine model of intestinal adaptation. 2D DIGE analysis of ileal epithelium from piglets recovering from massive small bowel resection (MSBR) identified over 60 proteins that changed specifically in MSBR animals relative to nonoperational or sham-operated controls. Three fatty acid binding proteins (L-FABP, FABP-6, and I-FABP) showed changes in MSBR animals. The expression changes and localization of each FABP were validated by immunoblotting and immunohistochemical analysis. FABP expression changes in MSBR animals occurred concurrently with altered triglyceride and bile acid metabolism as well as weight gain. The observed FABP expression changes in the ileal epithelium occur as part of the intestinal adaptation response and could provide a clinically useful marker to evaluate adaptation following MSBR.