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Gondolesi GE. History of clinical intestinal transplantation. Hum Immunol 2024; 85:110788. [PMID: 38519405 DOI: 10.1016/j.humimm.2024.110788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/27/2024] [Accepted: 03/11/2024] [Indexed: 03/24/2024]
Abstract
The intestines have been considered the "forbidden organ" for years, and intestinal failure became the last organ failure recognized as such in the medical field. The impossibility of providing adequate nutritional support, turned these patients into recipients of just palliative comfort. In the 1960's, parenteral nutrition appeared as the most reasonable replacement therapy, but the initial success obtained with clinical kidney, heart, liver, lung and pancreas transplantation served as background to explore intestinal transplantation. The first clinical report of an isolated intestinal transplant was done by Richard Lillihei in 1967; in 1983, Thomas Starzl, performed the first multi visceral transplant, and in 1990, David Grant performed the first combined liver-intestinal transplant in an adult recipient in Canada. Since then, advances in immunosuppressive therapies and surgical innovations have allowed not only a continuous increase in indications, but also a worldwide application of all procedures, bringing clinical intestinal transplantation to reality. In this historical account, the most important contributions have been summarized, thus describing the steady progress, expansion and novelties developed over the last 56 years, since the first attempt. Clinical intestinal transplantation remains a complex and evolving field; ongoing research and technological advancements will continue shaping its future.
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Affiliation(s)
- Gabriel E Gondolesi
- Chief of General Surgery, Chief of Liver, Intestine and Pancreas Transplant, Hospital Universitario, Fundación Favaloro, Buenos Aires, Argentina.
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2
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Hong JS, Shamim A, Atta H, Nonnecke EB, Merl S, Patwardhan S, Manell E, Gunes E, Jordache P, Chen B, Lu W, Shen B, Dionigi B, Kiran RP, Sykes M, Zorn E, Bevins CL, Weiner J. Application of enzyme-linked immunosorbent assay to detect antimicrobial peptides in human intestinal lumen. J Immunol Methods 2024; 525:113599. [PMID: 38081407 PMCID: PMC10956375 DOI: 10.1016/j.jim.2023.113599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023]
Abstract
Intestinal transplantation is the definitive treatment for intestinal failure. However, tissue rejection and graft-versus-host disease are relatively common complications, necessitating aggressive immunosuppression that can itself pose further complications. Tracking intraluminal markers in ileal effluent from standard ileostomies may present a noninvasive and sensitive way to detect developing pathology within the intestinal graft. This would be an improvement compared to current assessments, which are limited by poor sensitivity and specificity, contributing to under or over-immunosuppression, respectively, and by the need for invasive biopsies. Herein, we report an approach to reproducibly analyze ileal fluid obtained through stoma sampling for antimicrobial peptide/protein concentrations, reasoning that these molecules may provide an assessment of intestinal homeostasis and levels of intestinal inflammation over time. Concentrations of lysozyme (LYZ), myeloperoxidase (MPO), calprotectin (S100A8/A9) and β-defensin 2 (DEFB2) were assessed using adaptations of commercially available enzyme-linked immunosorbent assays (ELISAs). The concentration of α-defensin 5 (DEFA5) was assessed using a newly developed sandwich ELISA. Our data support that with proper preparation of ileal effluent specimens, precise and replicable determination of antimicrobial peptide/protein concentrations can be achieved for each of these target molecules via ELISA. This approach may prove to be reliable as a clinically useful assessment of intestinal homeostasis over time for patients with ileostomies.
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Affiliation(s)
- Julie S Hong
- Columbia Center of Translational Immunology, Department of Medicine, Columbia University, New York, NY, United States of America.
| | - Abrar Shamim
- Columbia Center of Translational Immunology, Department of Medicine, Columbia University, New York, NY, United States of America; College of Dental Medicine, Columbia University, New York, NY, United States of America
| | - Hussein Atta
- Columbia Center of Translational Immunology, Department of Medicine, Columbia University, New York, NY, United States of America
| | - Eric B Nonnecke
- Department of Microbiology and Immunology, University of California Davis School of Medicine, Davis, CA, United States of America
| | - Sarah Merl
- Department of Pathology and Cell Biology, Columbia University, New York, NY, United States of America
| | - Satyajit Patwardhan
- Columbia Center of Translational Immunology, Department of Medicine, Columbia University, New York, NY, United States of America
| | - Elin Manell
- Columbia Center of Translational Immunology, Department of Medicine, Columbia University, New York, NY, United States of America; Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Esad Gunes
- Columbia Center of Translational Immunology, Department of Medicine, Columbia University, New York, NY, United States of America
| | - Philip Jordache
- Columbia Center of Translational Immunology, Department of Medicine, Columbia University, New York, NY, United States of America
| | - Bryan Chen
- Columbia Center of Translational Immunology, Department of Medicine, Columbia University, New York, NY, United States of America
| | - Wuyuan Lu
- Department of Biochemistry and Molecular Biology, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Bo Shen
- Department of Surgery, Columbia University/New York-Presbyterian Hospital, New York, NY, United States of America
| | - Beatrice Dionigi
- Department of Surgery, Columbia University/New York-Presbyterian Hospital, New York, NY, United States of America
| | - Ravi P Kiran
- Department of Surgery, Columbia University/New York-Presbyterian Hospital, New York, NY, United States of America
| | - Megan Sykes
- Columbia Center of Translational Immunology, Department of Medicine, Columbia University, New York, NY, United States of America; Department of Surgery, Columbia University/New York-Presbyterian Hospital, New York, NY, United States of America
| | - Emmanuel Zorn
- Columbia Center of Translational Immunology, Department of Medicine, Columbia University, New York, NY, United States of America
| | - Charles L Bevins
- Department of Microbiology and Immunology, University of California Davis School of Medicine, Davis, CA, United States of America
| | - Joshua Weiner
- Columbia Center of Translational Immunology, Department of Medicine, Columbia University, New York, NY, United States of America; Department of Surgery, Columbia University/New York-Presbyterian Hospital, New York, NY, United States of America
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3
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Wei X, Tan X, Chen Q, Jiang Y, Wu G, Ma X, Fu J, Li Y, Gang K, Yang Q, Ni R, He J, Luo L. Extensive jejunal injury is repaired by migration and transdifferentiation of ileal enterocytes in zebrafish. Cell Rep 2023; 42:112660. [PMID: 37342912 DOI: 10.1016/j.celrep.2023.112660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 04/07/2023] [Accepted: 06/01/2023] [Indexed: 06/23/2023] Open
Abstract
A major cause of intestinal failure (IF) is intestinal epithelium necrosis and massive loss of enterocytes, especially in the jejunum, the major intestinal segment in charge of nutrient absorption. However, mechanisms underlying jejunal epithelial regeneration after extensive loss of enterocytes remain elusive. Here, we apply a genetic ablation system to induce extensive damage to jejunal enterocytes in zebrafish, mimicking the jejunal epithelium necrosis that causes IF. In response to injury, proliferation and filopodia/lamellipodia drive anterior migration of the ileal enterocytes into the injured jejunum. The migrated fabp6+ ileal enterocytes transdifferentiate into fabp2+ jejunal enterocytes to fulfill the regeneration, consisting of dedifferentiation to precursor status followed by redifferentiation. The dedifferentiation is activated by the IL1β-NFκB axis, whose agonist promotes regeneration. Extensive jejunal epithelial damage is repaired by the migration and transdifferentiation of ileal enterocytes, revealing an intersegmental migration mechanism of intestinal regeneration and providing potential therapeutic targets for IF caused by jejunal epithelium necrosis.
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Affiliation(s)
- Xiangyong Wei
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China
| | - Xinmiao Tan
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China
| | - Qi Chen
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China
| | - Yan Jiang
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China
| | - Guozhen Wu
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China
| | - Xue Ma
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China
| | - Jialong Fu
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China
| | - Yongyu Li
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China
| | - Kai Gang
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China
| | - Qifen Yang
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China
| | - Rui Ni
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China
| | - Jianbo He
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China
| | - Lingfei Luo
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China.
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Chung CS, Tsai CC, Chen KC, Lin CK, Lee TH, Tsai HW, Chen Y. Surveillance of Rejection After Intestinal Transplantation Using an Image Enhanced Endoscopy "VENCH" Scoring System. Transplant Proc 2020; 53:364-370. [PMID: 33309060 DOI: 10.1016/j.transproceed.2020.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 10/01/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Graft rejection after intestinal transplantation remains challenging. We aimed to use endoscopy for rejection prediction. MATERIALS AND METHODS Patients ≥7 years old who underwent intestinal transplantation between November 2016 and September 2019 were prospectively enrolled. Magnifying endoscopy under narrow-band imaging was performed through ileostomy. Endoscopic findings were reported as five components (each graded from 0-2): "V" (villi appearance), "E" (erythema), "N" (capillary network), "C" (crypt widening), and "H" (heterogeneity). The correlation between histological severity and endoscopic score was analyzed. RESULTS Ninety-nine endoscopic biopsies from three female and one male patient were analyzed. The mean ± SD age was of 41.25±13.77 (range 29-58) years. Three short bowel syndrome patients after multiple intestinal resections and one with chronic intestinal pseudo-obstruction were indicated for intestinal transplantation. Sensitivity, specificity, and accuracy of V, E, N, C, and H scores for predicting rejection were 97.4%, 45.9%, 65.7%; 94.7%, 70.5%, 79.8%; 97.4%, 52.5%, 69.7%; 94.7%, 54.1%, 69.7%; and 97.4%, 62.3%, 75.8%, respectively. Pearson's correlation coefficients between total and individual V, E, N, C, H scores and histological rejection were 0.79, 0.64, 0.70, 0.71, 0.73, and 0.66, respectively (P < .001). To predict mild and moderate/severe rejection, total scores more than 4 and 6 had the sensitivity/specificity of 87.50%/57.38% and 96.67%/85.25%, respectively (area under the ROC 0.791 and 0.987). CONCLUSION Endoscopic VENCH scoring is promising for predicting rejection after IT. More studies are warranted to validate such results. (ClinicalTrials.gov number, NCT03616548.).
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Affiliation(s)
- Chen-Shuan Chung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan; Taiwan Association for the Study of Small Intestinal Diseases (TASSID), Taoyuan City, Taiwan; College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chien-Chen Tsai
- Department of Anatomical Pathology, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Kuan-Chih Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan; Taiwan Association for the Study of Small Intestinal Diseases (TASSID), Taoyuan City, Taiwan
| | - Cheng-Kuan Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Tzong-Hsi Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan; Taiwan Association for the Study of Small Intestinal Diseases (TASSID), Taoyuan City, Taiwan
| | - Huang-Wen Tsai
- Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Yun Chen
- Taiwan Association for the Study of Small Intestinal Diseases (TASSID), Taoyuan City, Taiwan; Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan; Department of Chemical Engineering and Materials Science, Yuan Ze University, Taoyuan City, Taiwan.
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5
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van Haaften WT, Blokzijl T, Hofker HS, Olinga P, Dijkstra G, Bank RA, Boersema M. Intestinal stenosis in Crohn's disease shows a generalized upregulation of genes involved in collagen metabolism and recognition that could serve as novel anti-fibrotic drug targets. Therap Adv Gastroenterol 2020; 13:1756284820952578. [PMID: 32922514 PMCID: PMC7457685 DOI: 10.1177/1756284820952578] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 07/31/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND AND AIMS Crohn's disease (CD) can be complicated by intestinal fibrosis. Pharmacological therapies against intestinal fibrosis are not available. The aim of this study was to determine whether pathways involved in collagen metabolism are upregulated in intestinal fibrosis, and to discuss which drugs might be suitable to inhibit excessive extracellular matrix formation targeting these pathways. METHODS Human fibrotic and non-fibrotic terminal ileum was obtained from patients with CD undergoing ileocecal resection due to stenosis. Genes involved in collagen metabolism were analyzed using a microfluidic low-density TaqMan array. A literature search was performed to find potential anti-fibrotic drugs that target proteins/enzymes involved in collagen synthesis, its degradation and its recognition. RESULTS mRNA expression of collagen type I (COL1A1, 0.76 ± 0.28 versus 37.82 ± 49.85, p = 0.02) and III (COL3A1, 2.01 ± 2.61 versus 68.65 ± 84.07, p = 0.02) was increased in fibrotic CD compared with non-fibrotic CD. mRNA expression of proteins involved in both intra- and extracellular post-translational modification of collagens (prolyl- and lysyl hydroxylases, lysyl oxidases, chaperones), collagen-degrading enzymes (MMPs and cathepsin-K), and collagen receptors were upregulated in the fibrosis-affected part. A literature search on the upregulated genes revealed several potential anti-fibrotic drugs. CONCLUSION Expression of genes involved in collagen metabolism in intestinal fibrosis affected terminal ileum of patients with CD reveals a plethora of drug targets. Inhibition of post-translational modification and altering collagen metabolism might attenuate fibrosis formation in the intestine in CD. Which compound has the highest potential depends on a combination anti-fibrotic efficacy and safety, especially since some of the enzymes play key roles in the physiology of collagen.
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Affiliation(s)
- Wouter Tobias van Haaften
- Department of Gastroenterology and Hepatology,
University Medical Center Groningen, University of Groningen, Groningen, the
Netherlands
- Department of Pharmaceutical Technology and
Biopharmacy, University of Groningen, Groningen, the Netherlands
| | - Tjasso Blokzijl
- Department of Laboratory Medicine, University of
Groningen, University Medical Center Groningen, Groningen, The
Netherlands
| | - Hendrik Sijbrand Hofker
- Department of Surgery, University Medical Center
Groningen, University of Groningen, Groningen, the Netherlands
| | - Peter Olinga
- Department of Pharmaceutical Technology and
Biopharmacy, University of Groningen, Ant. Deusinglaan 1, Groningen, 9713
AV, the Netherlands
| | - Gerard Dijkstra
- Department of Gastroenterology and Hepatology,
University Medical Center Groningen, University of Groningen, Groningen, the
Netherlands
| | - Ruud A. Bank
- Department of Pathology and Medical Biology,
University Medical Center Groningen, University of Groningen, Groningen, the
Netherlands
| | - Miriam Boersema
- Department of Pharmaceutical Technology and
Biopharmacy, University of Groningen, Groningen, the Netherlands
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Solar H, Doeyo M, Ortega M, De Barrio S, Olano E, Moreira E, Buncuga M, Manzur A, Crivelli A, Gondolesi G. Postsurgical Intestinal Rehabilitation Using Semisynthetic Glucagon‐Like Peptide‐2 Analogue (sGLP‐2) at a Referral Center: Can Patients Achieve Parenteral Nutrition and sGLP‐2 Independency? JPEN J Parenter Enteral Nutr 2020; 45:1072-1082. [DOI: 10.1002/jpen.1983] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/27/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Hector Solar
- Intestinal Failure, Rehabilitation and Transplant Unit, Favaloro Foundation University Hospital Buenos Aires Argentina
- Translational Medicine, Transplantation and Bioengineering Research Institute (IMeTTyB) Favaloro University Buenos Aires Argentina
| | - Mariana Doeyo
- Intestinal Failure, Rehabilitation and Transplant Unit, Favaloro Foundation University Hospital Buenos Aires Argentina
- Translational Medicine, Transplantation and Bioengineering Research Institute (IMeTTyB) Favaloro University Buenos Aires Argentina
| | - Mariana Ortega
- Intestinal Failure, Rehabilitation and Transplant Unit, Favaloro Foundation University Hospital Buenos Aires Argentina
- Translational Medicine, Transplantation and Bioengineering Research Institute (IMeTTyB) Favaloro University Buenos Aires Argentina
| | - Silvia De Barrio
- Nutritional Support and Malabsorptive Disorders Unit San Martin Hospital La Plata Argentina
| | - Estela Olano
- Special Nutrition Unit Maciel Hospital Montevideo Uruguay
| | | | - Martin Buncuga
- Nutritional Support Unit Delta Hospital Rosario Argentina
| | - Alejandra Manzur
- Organ and Tissue Transplant Department Central Hospital Mendoza Argentina
| | - Adriana Crivelli
- Intestinal Failure, Rehabilitation and Transplant Unit, Favaloro Foundation University Hospital Buenos Aires Argentina
- Translational Medicine, Transplantation and Bioengineering Research Institute (IMeTTyB) Favaloro University Buenos Aires Argentina
| | - Gabriel Gondolesi
- Intestinal Failure, Rehabilitation and Transplant Unit, Favaloro Foundation University Hospital Buenos Aires Argentina
- Translational Medicine, Transplantation and Bioengineering Research Institute (IMeTTyB) Favaloro University Buenos Aires Argentina
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Gondolesi GE, Doeyo M, Echevarria Lic C, Lobos F, Rubio S, Rumbo C, Ramisch D, Crivelli A, Schelotto PB, Solar H. Results of Surgical and Medical Rehabilitation for Adult Patients With Type III Intestinal Failure in a Comprehensive Unit Today: Building a New Model to Predict Parenteral Nutrition Independency. JPEN J Parenter Enteral Nutr 2019; 44:703-713. [DOI: 10.1002/jpen.1686] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 06/27/2019] [Accepted: 07/03/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Gabriel E. Gondolesi
- Intestinal Failure, Rehabilitation and Transplant Unit Favaloro Foundation University Hospital Fundacion Favaloro Buenos Aires Argentina
- Translational Medicine Transplantation and Bioengineering Research Institute (IMeTTyB) Favaloro University Buenos Aires Argentina
| | - Mariana Doeyo
- Intestinal Failure, Rehabilitation and Transplant Unit Favaloro Foundation University Hospital Fundacion Favaloro Buenos Aires Argentina
- Translational Medicine Transplantation and Bioengineering Research Institute (IMeTTyB) Favaloro University Buenos Aires Argentina
| | - Constanza Echevarria Lic
- Intestinal Failure, Rehabilitation and Transplant Unit Favaloro Foundation University Hospital Fundacion Favaloro Buenos Aires Argentina
- Translational Medicine Transplantation and Bioengineering Research Institute (IMeTTyB) Favaloro University Buenos Aires Argentina
| | - Fernando Lobos
- Intestinal Failure, Rehabilitation and Transplant Unit Favaloro Foundation University Hospital Fundacion Favaloro Buenos Aires Argentina
- Translational Medicine Transplantation and Bioengineering Research Institute (IMeTTyB) Favaloro University Buenos Aires Argentina
| | - Santiago Rubio
- Intestinal Failure, Rehabilitation and Transplant Unit Favaloro Foundation University Hospital Fundacion Favaloro Buenos Aires Argentina
- Translational Medicine Transplantation and Bioengineering Research Institute (IMeTTyB) Favaloro University Buenos Aires Argentina
| | - Carolina Rumbo
- Intestinal Failure, Rehabilitation and Transplant Unit Favaloro Foundation University Hospital Fundacion Favaloro Buenos Aires Argentina
- Translational Medicine Transplantation and Bioengineering Research Institute (IMeTTyB) Favaloro University Buenos Aires Argentina
| | - Diego Ramisch
- Intestinal Failure, Rehabilitation and Transplant Unit Favaloro Foundation University Hospital Fundacion Favaloro Buenos Aires Argentina
- Translational Medicine Transplantation and Bioengineering Research Institute (IMeTTyB) Favaloro University Buenos Aires Argentina
| | - Adriana Crivelli
- Intestinal Failure, Rehabilitation and Transplant Unit Favaloro Foundation University Hospital Fundacion Favaloro Buenos Aires Argentina
- Translational Medicine Transplantation and Bioengineering Research Institute (IMeTTyB) Favaloro University Buenos Aires Argentina
| | - Pablo Barros Schelotto
- Intestinal Failure, Rehabilitation and Transplant Unit Favaloro Foundation University Hospital Fundacion Favaloro Buenos Aires Argentina
- Translational Medicine Transplantation and Bioengineering Research Institute (IMeTTyB) Favaloro University Buenos Aires Argentina
| | - Hector Solar
- Intestinal Failure, Rehabilitation and Transplant Unit Favaloro Foundation University Hospital Fundacion Favaloro Buenos Aires Argentina
- Translational Medicine Transplantation and Bioengineering Research Institute (IMeTTyB) Favaloro University Buenos Aires Argentina
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8
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Management of intestinal failure in middle-income countries, for children and adults. Curr Opin Organ Transplant 2018; 23:212-218. [DOI: 10.1097/mot.0000000000000512] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Ramisch D, Rumbo C, Echevarria C, Moulin L, Niveyro S, Orce G, Crivelli A, Martinez MI, Chavez L, Paez MA, Trentadue J, Klein F, Fernández A, Solar H, Gondolesi GE. Long-Term Outcomes of Intestinal and Multivisceral Transplantation at a Single Center in Argentina. Transplant Proc 2017; 48:457-62. [PMID: 27109978 DOI: 10.1016/j.transproceed.2015.12.066] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 12/29/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Intestinal failure (IF) patients received parenteral nutrition (PN) as the only available therapy until intestinal transplantation (ITx) evolved as an accepted treatment. The aim of this article is to report the long-term outcomes of a series of ITx performed in pediatric and adult patients at a single center 9 years after its creation. PATIENTS AND METHODS This is a retrospective analysis of the ITx performed between May 2006 and January 2015. Diagnoses, pre-ITx mean time on PN, indications for ITx, time on the waiting list for types of ITx, mean total ischemia time, and warm ischemia time, time until PN discontinuation, incidence of acute and chronic rejection, and 5-year actuarial patient survival are reported. RESULTS A total of 42 patients received ITx; 80% had short gut syndrome (SG); the mean time on PN was 1620 days. The main indication for ITx was lack of central venous access followed by intestinal failure-associated liver disease (IFALD) and catheter-related infectious complications. The mean time on the waiting list was 188 days (standard deviation, ±183 days). ITx were performed in 26 children and 14 adults. In all, 32 procedures were isolated ITx (IITX); 10 were multiorgan Tx (MOT; 3 combined, 7 multivisceral Tx (MVTx), 1 modified MVTx and 2 with kidney); 2 (4.7 %) were retransplantations: 1 IITx, 1 MVTx, and 5 including the right colon. Thirteen patients (31%) received abdominal rectus fascia. All procedures were performed by the same surgical team. Total ischemia time was 7:53 ± 2:04 hours, and warm ischemia time was 40.2 ± 10.5 minutes. The mean length of implanted intestine was 325 ± 63 cm. Bishop-Koop ileostomy was performed in 67% of cases. In all, 16 of 42 Tx required early reoperations. The overall mean follow-up time was 41 ± 35.6 months. The mean time to PN discontinuation after Tx was 68 days (P = .001). The total number of acute cellular rejection (ACR) episodes until the last follow-up was 83; the total number of grafts lost due to ACR was 4; and the total graft lost due to chronic rejection was 3. At the time of writing, the overall 5-year patient survival is 55% (65% for IITx vs 22% for MOT; P = .0001); 60% for pediatric recipients vs 47% for adults (P = NS); 64% when the indication for ITx was SG vs 25% for non-SG (P = .002). CONCLUSIONS At this center, candidates with SG, in the absence of IFALD requiring IITx, showed the best long-term outcomes, independent of recipient age. A multidisciplinary approach is mandatory for the care of intestinal failure patients, to sustain a rehabilitation and transplantation program over time.
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Affiliation(s)
- D Ramisch
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - C Rumbo
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - C Echevarria
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - L Moulin
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - S Niveyro
- Anesthesia Department, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - G Orce
- Anesthesia Department, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - A Crivelli
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - M I Martinez
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - L Chavez
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - M A Paez
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - J Trentadue
- Pediatric Intensive Care Unit, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - F Klein
- Adult Intensive Care Unit, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - A Fernández
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - H Solar
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - G E Gondolesi
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina.
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10
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Meier D, Rumbo M, Gondolesi GE. Current Status of Allograft Tolerance in Intestinal Transplantation. Int Rev Immunol 2013; 33:245-60. [DOI: 10.3109/08830185.2013.829468] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Trevizol AP, David AI, Yamashita ET, Pecora RA, D'Albuquerque LA. Intestinal and multivisceral retransplantation results: literature review. Transplant Proc 2013; 45:1133-6. [PMID: 23622645 DOI: 10.1016/j.transproceed.2013.03.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Intestinal/multivisceral transplantation (IT/MVT) is the gold standard treatment for patients with intestinal failure and complications related to total parenteral nutrition, gastrointestinal inoperable indolent tumors, or diffuse portal trombosis. Currently, the reported 1-year patient survival rate is around 80%, similar to other solid organ abdominal transplantations. Unfortunately, the patient survival decreases after the first year with the 5-year rate not close to 70% yet. Acute cellular rejection is the main cause of graft loss. Its early diagnosis may make it possible to improve survival of retransplantations. OBJECTIVE To analyze the reported results published in the last 5 years by leading transplant centers to evaluate IT/MVT retransplantation results. METHODS We performed a literature review using PubMed focusing on multivisceral and intestinal retransplantation in articles published between 2006 and 2012. In relation to the first transplantation, we analyzed demographics, imunosuppression, rejection, infection as well as graft and patient survival rates. RESULTS Two centers reported results on intestinal and multivisceral retransplantations. Mazariegos et al reported their experience with 15 intestinal retransplantations in 14 pediatric recipients. Four patients died from posttransplant lymphoperliferative disease, severe acute cellular rejection, fungal sepsis, or bleeding from a pseudoaneurysm at a mean time of 5.7 months post-transplantation. Total parenteral nutrition was weaned at a median time of 32 days. Abu-Elmaged et al reported 47 cases with a 5-year survival of 47% for all retransplant modalities. Retransplantation with liver-contained visceral allograft achieved a 5-year survival rate of 61% compared with 16% for liver-free visceral grafts. CONCLUSION Despite those huge improvements, some transplanted patients develop severe acute cellular rejection, culminating in graft loss and retransplantation. Repots on multivisceral and intestinal retransplantation outcomes suggest that it is a viable procedure with appropriate patient survival after primary graft loss.
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Erkrankungen und Therapieformen des unteren Gastrointestinaltrakts. PÄDIATRISCHE GASTROENTEROLOGIE, HEPATOLOGIE UND ERNÄHRUNG 2013. [PMCID: PMC7498818 DOI: 10.1007/978-3-642-24710-1_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Duodenalatresien sind Hemmungsfehlbildungen und können proximal oder distal der Papilla Vateri entstehen, wobei die präpapillären Obstruktionen selten sind. Grundsätzlich kann zwischen einer Membranatresie und einer Defektatresie unterschieden werden. Die Unterscheidung beruht nicht nur auf embryologischen Gesichtspunkten, sondern hat auch eine klinische Bedeutung: Bei der Membranatresie kann die quergestellte, partiell offene oder geschlossene Membran weit in den distalen Duodenalanteil reichen („Windsackphänomen“), was zu diagnostischen und auch intraoperativen Problemen führen kann. Ein Pancreas anulare findet sich bei etwa 20 % aller Patienten mit Duodenalatresie.
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Asaoka T, Sotolongo B, Island ER, Tryphonopoulos P, Selvaggi G, Moon J, Tekin A, Amador A, Levi DM, Garcia J, Smith L, Nishida S, Weppler D, Tzakis AG, Ruiz P. MicroRNA signature of intestinal acute cellular rejection in formalin-fixed paraffin-embedded mucosal biopsies. Am J Transplant 2012; 12:458-68. [PMID: 22026534 DOI: 10.1111/j.1600-6143.2011.03807.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Despite continuous improvement of immunosuppression, small bowel transplantation (SBT) is plagued by a high incidence of acute cellular rejection (ACR) that is frequently intractable. Therefore, there is a need to uncover novel insights that will lead to strategies to achieve better control of ACR. We hypothesized that particular miRNAs provide critical regulation of the intragraft immune response. The aim of our study was to identify miRNAs involved in intestinal ACR. We examined 26 small intestinal mucosal biopsies (AR/NR group; 15/11) obtained from recipients after SBT or multivisceral transplantation. We investigated the expression of 384 mature human miRNAs and 280 mRNAs associated with immune, inflammation and apoptosis processes. We identified differentially expressed 28 miRNAs and 58 mRNAs that characterized intestinal ACR. We found a strong positive correlation between the intragraft expression levels of three miRNAs (miR-142-3p, miR-886-3p and miR-132) and 17 mRNAs including CTLA4 and GZMB. We visualized these miRNAs within cells expressing CD3 and CD14 proteins in explanted intestinal allografts with severe ACR. Our data suggested that miRNAs have a critical role in the activation of infiltrating cells during intestinal ACR. These differences in miRNA expression patterns can be used to identify novel biomarkers and therapeutic targets for immunosuppressive agents.
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Affiliation(s)
- T Asaoka
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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Akhter K, Timpone J, Matsumoto C, Fishbein T, Kaufman S, Kumar P. Six-month incidence of bloodstream infections in intestinal transplant patients. Transpl Infect Dis 2011; 14:242-7. [PMID: 22093913 DOI: 10.1111/j.1399-3062.2011.00683.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Revised: 07/19/2011] [Accepted: 08/13/2011] [Indexed: 01/29/2023]
Abstract
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.
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Affiliation(s)
- K Akhter
- Infectious Diseases Faculty Practice, Orlando Health, Orlando, Florida 32806, USA.
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Asaoka T, Island ER, Tryphonopoulos P, Selvaggi G, Moon J, Tekin A, Amador A, Levi DM, Garcia J, Smith L, Nishida S, Weppler D, Tzakis AG, Ruiz P. Characteristic immune, apoptosis and inflammatory gene profiles associated with intestinal acute cellular rejection in formalin-fixed paraffin-embedded mucosal biopsies. Transpl Int 2011; 24:697-707. [DOI: 10.1111/j.1432-2277.2011.01259.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Lee MD. Management Strategies for Patients with Chronic Intestinal Failure Who Are Potential Candidates for a Future Intestinal Transplant. KOREAN JOURNAL OF TRANSPLANTATION 2010. [DOI: 10.4285/jkstn.2010.24.4.248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Myung Duk Lee
- Department of Pediatric Surgery, Seoul St. Mary's Hospital, Seoul, Korea
- Department of General Surgery, School of Medicine, The Catholic University of Korea, Seoul, Korea
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Abstract
Only 50 years ago intestinal failure was considered incompatible with life. Since then, developments in parenteral nutrition, and, more recently, small intestinal transplantation, have provided new therapeutic options with the potential to offer long-term survival with a good quality of life. Current medical and surgical strategies are aimed at enhancing intestinal adaptation, improving absorption to achieve nutritional independence, and minimizing the complications of parenteral nutrition therapy. An integrated, multidisciplinary approach to the management of patients with intestinal failure, closely linked to a transplantation program to facilitate early referral, is recognized as a key factor in optimizing patient outcomes.
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Affiliation(s)
- Julie E Bines
- Department of Pediatrics, University of Melbourne, Flemington Road, Parkville, Vic. 3052, Australia.
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Rapid reversal of parenteral-nutrition-associated cirrhosis following isolated intestinal transplantation. J Gastrointest Surg 2009; 13:1717-23. [PMID: 19418102 DOI: 10.1007/s11605-009-0914-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2009] [Accepted: 04/15/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Liver disease and the development of hepatic fibrosis are complications associated with total parenteral nutrition (TPN). Patients developing cirrhosis and portal hypertension in the setting of intestinal failure have a high mortality and may require combined liver and intestinal transplantation which carries much higher morbidity and mortality than isolated intestinal transplantation. DISCUSSION Recently, regression of hepatic fibrosis in patients with TPN liver disease has been described following intestinal transplantation. To date, there has been no demonstration of the reversal of established cirrhosis due to long-term TPN injury. Herein, we describe a patient with intestinal failure who developed cirrhosis from long-standing TPN injury and underwent isolated intestinal transplantation. He had no overt clinical stigmata of portal hypertension and had preserved liver function. Serial liver biopsies were reviewed and assessed with standard histology and quantitation of fibrosis using image analysis. Dramatic regression of fibrosis and reversal of cirrhosis were observed 17 months posttransplantation. Image analysis demonstrated a 14% total decrease in the percentage area of fibrosis. CONCLUSIONS Cirrhosis related to TPN may be rapidly reversible after isolated intestinal transplantation. Such patients may be able to undergo isolated intestinal transplantation if they do not have hepatic synthetic compromise or clinical stigmata of portal hypertension.
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Fishbein TM, Novitskiy G, Lough DM, Matsumoto C, Kaufman SS, Shetty K, Zasloff M. Rejection reversibly alters enteroendocrine cell renewal in the transplanted small intestine. Am J Transplant 2009; 9:1620-8. [PMID: 19519821 DOI: 10.1111/j.1600-6143.2009.02681.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Acute small intestinal allograft rejection presents clinically as an abrupt increase in ileal fluid output in the absence of extensive inflammation. We questioned whether acute intestinal rejection might be accompanied by a disturbance of normal intestinal stem cell differentiation. We examined the intestinal epithelial secretory cell lineage among patients experiencing early rejection before and during rejection as well as following corrective therapy. Lineage-specific progenitors were identified by their expression of stage-specific transcription factors. Progenitors of the enteroendocrine cell (EEC) expressing neurogenin-3 (NEUROG3) were found to be disproportionately reduced in numbers, along with their more mature EEC derivatives expressing neuro D; the enteric hormone PYY was the most profoundly depleted of all the EEC products evaluated. No change in the numbers of goblet or Paneth cells was observed. Steroid treatment resulted in resolution of clinical symptoms, restoration of normal patterns of EEC differentiation and recovery of normal levels of enteric hormones. Acute intestinal rejection is associated with a loss of certain subtypes of EEC, most profoundly, those expressing PYY. Deficiency of the mature EECs appears to occur as a consequence of a mechanism that depletes NEUROG3 EEC progenitors. Our study highlights the dynamics of the EEC lineage during acute intestinal rejection.
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Affiliation(s)
- T M Fishbein
- Transplant Institute, Georgetown University Medical Center, Washington, DC, USA.
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20
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ESPEN Guidelines on Parenteral Nutrition: home parenteral nutrition (HPN) in adult patients. Clin Nutr 2009; 28:467-79. [PMID: 19464089 DOI: 10.1016/j.clnu.2009.04.001] [Citation(s) in RCA: 255] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Accepted: 04/01/2009] [Indexed: 12/28/2022]
Abstract
Home parenteral nutrition (HPN) was introduced as a treatment modality in the early 1970s primarily for the treatment of chronic intestinal failure in patients with benign disease. The relatively low morbidity and mortality associated with HPN has encouraged its widespread use in western countries. Thus there is huge clinical experience, but there are still few controlled clinical studies of treatment effects and management of complications. The purpose of these guidelines is to highlight areas of good practice and promote the use of standardized treatment protocols between centers. The guidelines may serve as a framework for development of policies and procedures.
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Colomb V, Goulet O. Nutrition support after intestinal transplantation: how important is enteral feeding? Curr Opin Clin Nutr Metab Care 2009; 12:186-9. [PMID: 19209470 DOI: 10.1097/mco.0b013e328323280f] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Intestinal transplantation is the alternative treatment in patients with irreversible intestinal failure, who depend on long-term parenteral nutrition. Nutrition management after intestinal transplantation should contribute to reducing the risk of graft rejection, to improving gut trophicity and should optimize nutrient absorption, the main goal being to achieve full intestinal autonomy. RECENT FINDINGS Enteral feeding can be administered into the stomach, or directly into the jejunum. Semi-elemental diets are usually used with the aim of improving nutrient absorption and limiting food antigen overload, which might trigger immune stimulation with subsequent increased risk of acute graft rejection. There is no evidence-based reason to use amino acid-based formula. The feeding usually starts with a dilute semi-elemental formula and with a low rate of delivery. The rate and strength of the formula are slowly increased thereafter, according to the individual tolerance. Chylous ascitis and fat malabsorption impair both short-term and long-term nutritional results and are likely to be due to an insufficient reestablishment of the lymphatic circulation of the graft. After an intestinal transplant, patients usually achieve linear growth. However, catch-up growth is rarely observed in stunted patients. SUMMARY Nutritional management after intestinal transplantation is challenging and requires a trained, specialized multidisciplinary team.
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Affiliation(s)
- Virginie Colomb
- Pediatric Gastroenterology, Hepatology and Nutrition centre, Pediatric Home Parenteral Nutrition centre, Hôpital Necker-Enfants Malades, Paris, France.
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22
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Collaborative strategies to reduce mortality and morbidity in patients with chronic intestinal failure including those who are referred for small bowel transplantation. Transplantation 2008; 85:1378-84. [PMID: 18497673 DOI: 10.1097/tp.0b013e31816dd513] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
UNLABELLED Intestinal transplant wait-list mortality is higher than for other organ transplants. The objective of this workshop was to identify the main problems contributing to high mortality in adults and children candidates for intestinal transplantation and provide recommendations on how to correct them. OUTCOME To facilitate this, 63 relevant articles identified from the medical literature from 1987 to 2007 were reviewed. Consensus was achieved on several important definitions relevant to this review. For children and adults on parenteral nutrition (PN) the main mortality risk factors were identified as were the main risks of mortality for those on the waiting list for intestinal transplants. RECOMMENDATIONS (1) Primary care givers managing intestinal failure patients should establish a link with an intestinal failure programs early and collaboration with intestinal failure programs should be initiated for patients whose PN requirements are anticipated to be more than 50% 3 months after initiating PN; (2) intestinal failure programs should include both intestinal rehabilitation and intestinal transplantation or have active collaborative relationships with centers performing intestinal transplantation; (3) National registries for intestinal failure patients should be established and organizations that provide home PN solutions should be expected to participate. CONCLUSION There are many unresolved issues in adults and children with PN dependent intestinal failure. To address these, a key recommendation of this group is to establish national intestinal failure databases that can support multicenter studies and lead to the adoption of universally accepted standards of patient care with the goal of improving outcomes in all long-term intestinal failure patients including those requiring intestinal transplantation.
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23
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Transplantation of the Intestine. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Königsrainer A, Ladurner R, Iannetti C, Steurer W, Ollinger R, Offner F, Kreczy A, Margreiter R. The ?Blind Innsbruck Ostomy?, a cutaneous enterostomy for long-term histologic surveillance after small bowel transplantation. Transpl Int 2007; 20:867-74. [PMID: 17711406 DOI: 10.1111/j.1432-2277.2007.00541.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Intestinal transplantation has evolved into an established treatment for patients with intestinal failure. Although acute rejection episodes are reversible, late onset and chronic rejections remain major prognostic factors. We describe here our experience with endoscopic and histologic long-term monitoring through a cutaneous enterostomy. Between 1989 and 2003, 24 intestinal transplants were performed. After revascularization and reconstruction of proximal intestinal continuity, a side-to-end ileo-enterostomy was performed 20 cm from the stoma and the terminal allograft ileostomy left in the abdominal wall. Approximately after 2 months, in eight patients (nine transplants), the stoma was excluded from the gastrointestinal continuity, allowing ongoing endoscopy and histologic examination. Of 280 forceps biopsies, 64 (23%) were performed through the 'blind ostomy'. Eleven acute allograft rejections were diagnosed between days 3 and 51, with two episodes in three cases. Through the 'blind ostomy', a late mild acute rejection was diagnosed in five instances, three to 37 months after transplantation. In all these patients, basal immunosuppression was intensified. Chronic rejection was seen in three cases 4-26 months after transplantation. In one of the three patients, chronic rejection was diagnosed from the excluded blind enterostomy. A long-term cutaneous enterostomy, even if disconnected from the intestinal continuity, enables simple long-term monitoring of small bowel allografts.
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Affiliation(s)
- Alfred Königsrainer
- Department of General and Transplant Surgery, Innsbruck Medical University Hospital, Innsbruck, Austria.
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25
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Torres C, Sudan D, Vanderhoof J, Grant W, Botha J, Raynor S, Langnas A. Role of an intestinal rehabilitation program in the treatment of advanced intestinal failure. J Pediatr Gastroenterol Nutr 2007; 45:204-12. [PMID: 17667717 DOI: 10.1097/mpg.0b013e31805905f9] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To analyze outcomes in children with intestinal failure treated by our Intestinal Rehabilitation Program (IRP) in a 4-year period. PATIENTS AND METHODS A total of 51 parenteral nutrition (PN)-dependent patients (20 male) were enrolled in the IRP. Median age was 1.7 years, with the primary diagnoses being gastroschisis, necrotizing enterocolitis, volvulus, and congenital atresia. Median small bowel intestinal length was 35 cm, with the majority of patients having only jejunum as remaining bowel anatomy. Thirty-six of the 51 patients had liver disease characterized by cirrhosis, advance bridging fibrosis, and portal and periportal fibrosis. Height, weight z score, platelet count, albumin, and bilirubin levels were measured at the beginning and end of the study. RESULTS Of the 51 patients, 29 had 46 different surgical intestinal repairs. Twenty-nine of the 36 patients with hyperbilirubinemia had normalized serum bilirubin with treatment. Ten patients required transplantation. Five patients died of sepsis, influenza, or complications after intestinal transplantation. Of the remaining 37 patients in the IRP, 31 were weaned from parenteral nutrition (5 with cirrhosis); 6 patients are in the process of weaning. Survival rate of the patients in the IRP was 90%. Growth has continued along the same curve, and some patients have exhibited significant catch-up. CONCLUSIONS With an aggressive medical/surgical approach, even patients with intestinal failure and advanced liver disease can avoid transplantation. Patients in the IRP showed improved liver function and nutritional parameters with the ability to discontinue PN while maintaining growth. Early referral of these patients to specialized centers before the development of advanced liver disease is recommended.
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Affiliation(s)
- Clarivet Torres
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, USA.
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Yandza T, Schneider SM, Canioni D, Saint-Paul MC, Gugenheim J, Chevalier P, Goubaux B, Benchimol D, Hébuterne X. La greffe intestinale. ACTA ACUST UNITED AC 2007; 31:469-79. [PMID: 17541336 DOI: 10.1016/s0399-8320(07)89414-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Even though surgical techniques for isolated intestine, liver-intestine, and multivisceral transplantations were developed in the 1960's, very few patients were transplanted before 1990 because initial immunosuppression regimens were insufficient, making intestine transplantation impossible. Intestine transplantation resulted in death in most patients within days or months. The discouraging results of the first clinical trials were due to technical complications, sepsis, and the failure of conventional immunosuppression to control rejection. By 1990 the development of tacrolimus-based immunosuppression and improved surgical techniques, the increased array of potent immunosuppressive medications, infection prophylaxis, and suitable patient selection helped improve actuarial graft and patient survival rates for all types of intestine transplantation. The aims of this review are to describe the current status of intestine transplantation including the underlying diseases and conditions that may be indications for intestine transplantation, to identify patient populations for this indication, to provide key steps for patient evaluation, to summarize current recommendations for immunosuppression, to list the most common postoperative complications, and to discuss the international experience of small bowel transplantation compiled and analyzed by the International Intestine Transplant Registry since 1985.
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Affiliation(s)
- Thierry Yandza
- Service de Chirurgie Viscérale et de Transplantation Hépatique, Hôpital de L'Archet II, Centre Hospitalo-Universitaire de Nice, Nice, France.
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27
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DeLegge M, Alsolaiman MM, Barbour E, Bassas S, Siddiqi MF, Moore NM. Short bowel syndrome: parenteral nutrition versus intestinal transplantation. Where are we today? Dig Dis Sci 2007; 52:876-92. [PMID: 17380398 DOI: 10.1007/s10620-006-9416-6] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2006] [Accepted: 04/30/2006] [Indexed: 01/19/2023]
Abstract
Current management of short bowel syndrome (SBS) revolves around the use of home TPN (HPN). Complications include liver disease, catheter-related infections or occlusions, venous thrombosis, and bone disease. Patient survival with SBS on TPN is 86% and 75% at 2 and 5 years, respectively. Surgical management of SBS includes nontransplant surgeries such as serial transverse enteroplasty and reanastomosis. Small bowel transplant has become increasingly popular for management of SBS and is usually indicated when TPN cannot be continued. Posttransplant complications include graft-versus-host reaction, infections in an immunocompromised patient, vascular and biliary diseases, and recurrence of the original disease. Following intestinal-only transplants, patient and graft survival rate is 77% and 66% after 1 year. After 5 years the survival figures are 49% and 34%, respectively. Future improvements in survival and quality of life will enhance small bowel transplant as a viable treatment option for patients with SBS.
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28
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Vivarelli M, Lauro A, Cucchetti A, D'Errico A, Pironi L, Pinna AD. Effect of total enterectomy, pancreatectomy, and portal vein ligation on liver function and histology: a case report. Transplant Proc 2007; 39:300-2. [PMID: 17275528 DOI: 10.1016/j.transproceed.2006.10.209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2006] [Indexed: 11/24/2022]
Abstract
Impaired hepatic function and histology have been observed in experimental models of diversion of the portal vein blood inflow from the liver and among patients with intestinal failure. Survival after total enterectomy, pancreatectomy, and portal vein ligation, and the effect of such a condition on liver function have never been reported in humans. Herein a 32-year-old woman with familial adenomatous polyposis and multiple desmoid tumors involving the mesentery and the retroperitoneum underwent total enterectomy and pancreatectomy followed by en bloc transplantation of the stomach, small bowel, and pancreas. Due to early graft failure, the patient underwent graftectomy, ligation of the portal vein, and external drainage of the common bile duct. Liver function tests were checked daily and a liver biopsy performed 15 days after graftectomy. The patient died of a ruptured mycotic aneurysm of the abdominal aorta at 27 days after the graftectomy. Liver function tests remained normal throughout the postoperative period; liver biopsy showed normal hepatic architecture with mild portal inflammation and cholestasis and spotty necrosis. Total enterectomy with pancreatectomy and ligation of the portal vein are compatible with survival in humans (at least in the short term), allowing normal hepatic function with minimal histological alterations to the liver.
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Affiliation(s)
- M Vivarelli
- Department of Surgery, University of Bologna, S Orsola Hospital, Bologna, Italy
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Braun F, Broering D, Faendrich F. Small intestine transplantation today. Langenbecks Arch Surg 2007; 392:227-38. [PMID: 17252235 DOI: 10.1007/s00423-006-0134-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2006] [Accepted: 11/14/2006] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Intestinal transplantation has become a life-saving therapy in patients with irreversible loss of intestinal function and complications of total parenteral nutrition. DISCUSSION The patient and graft survival rates have improved over the last years, especially after the introduction of tacrolimus and rapamycin. However, intestinal transplantation is more challenging than other types of solid organ transplantation due to its large amount of immune competent cells and its colonization with microorganisms. Moreover, intestinal transplantation is still a low volume procedure with a small number of transplanted patients especially in Germany. A current matter of concern is the late referral of intestinal transplant candidates. CONCLUSION Thus, patients often present after onset of life-threatening complications or advanced cholestatic liver disease. Earlier timing of referral for candidacy might result in further improvement of this technique in the near future.
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Affiliation(s)
- Felix Braun
- Klinik für Allgemeine Chirurgie und Thoraxchirurgie, Zentrum Chirurgie, Universität Schleswig-Holstein, Campus Kiel, Arnold-Heller-Strasse 7, 24105 Kiel, Germany
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30
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Pironi L, Hébuterne X, Van Gossum A, Messing B, Lyszkowska M, Colomb V, Forbes A, Micklewright A, Villares JMM, Thul P, Bozzetti F, Goulet O, Staun M. Candidates for intestinal transplantation: a multicenter survey in Europe. Am J Gastroenterol 2006; 101:1633-43; quiz 1679. [PMID: 16863571 DOI: 10.1111/j.1572-0241.2006.00710.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Epidemiology of candidacy for intestinal transplantation (ITx) and timing for referral for ITx are unknown. Patient candidacy and physician attitudes toward ITx were investigated among centers that participated in previous European surveys on home parenteral nutrition (HPN). METHODS Patients on HPN for benign intestinal failure (IF) were evaluated by a structured questionnaire. Candidacy was assessed by USA Medicare and American Transplantation Society criteria, categorized as: (1) life-threatening HPN complications; (2) high risk of death because of the gastrointestinal disease; (3) IF with high morbidity or patient HPN refusal. Physicians judged candidacy as immediate or potential. RESULTS Forty-one centers from nine countries enrolled 688 adults (> 18 yr) and 166 pediatric patients; 70% of patients were from five countries which collected 60-100% of their HPN patients. Candidacy was 15.7% in adults and 34.3% in pediatrics (HPN failure, 62.1% and 28.1%; gastrointestinal disease, 25.9% and 59.6%; high morbidity IF or HPN refusal, 12.0% and 12.3%, respectively). Immediate candidacy was required for 14.8% of adult and 15.8% of pediatric candidates (< 50% of candidates because of HPN-related liver failure). Among centers, the candidacy rate ranged 0-100% and was negatively associated with the number of patients enrolled in the survey (R = -0.463, p = 0.002). Among the major contributing countries, candidacy ranged 0.3-0.8/million inhabitants for adults and 0.9-2/million inhabitants < or = 18 yr for pediatric candidates. CONCLUSIONS The rate of candidacy and the indications for ITx candidacy differed greatly among age groups and HPN centers; within countries candidacy was more homogeneous; physicians had a generally reserved attitude toward ITx.
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Affiliation(s)
- Loris Pironi
- Department of Internal Medicine and Gastroenterology, University of Bologna, Bologna, Italy
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Matsumoto C, Kaufman S, Fennelly E, Davis J, Gupta P, Fishbein TM. Impact of Positive Preoperative Surveillance Blood Cultures From Chronic Indwelling Catheters in Cadaveric Intestinal Transplant Recipients. Transplant Proc 2006; 38:1676-7. [PMID: 16908244 DOI: 10.1016/j.transproceed.2006.05.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Recurrent bloodstream infections are a common indication for intestinal transplantation (ITx). Often, clinical symptoms may be absent in the setting of bacteremia, especially in patients with chronic liver disease. This study investigated the incidence and impact of positive blood cultures (BCx) obtained from central venous catheters used for total parenteral nutrition (TPN) in asymptomatic patients immediately prior to cadaveric ITx. Of 13 consecutive patients transplanted between November 2003 and November 2004, 12 underwent preoperative surveillance BCx with four positives (33%). Isolates included Staphylococcus epidermidis (n = 2), methicillin-resistant Staphylococcus aureus, and Citrobacter freundii. All four patients with positive BCx displayed liver dysfunction at the time of transplant (> or = grade 2 fibrosis, total bilirubin >8.0 g/dL), three of whom were inpatients. In contrast, only three of eight nonbacteremic patients showed liver disease of comparable severity. Liver dysfunction and inpatient status at the time of transplant appear to predict positive blood cultures. Postoperative length of stay and time on the ventilator were significantly longer among bacteremic as compared with nonbacteremic patients, but there were no differences in intraoperative blood use, time to total parenteral nutrition independence, or operative time between bacteremic and nonbacteremic patients. Our study showed that occult bacteremia in asymptomatic pre-intestinal transplant patients was not uncommon and may increase postoperative morbidity. Preemptive removal of long-term central venous catheters should be considered prior to ITx.
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Affiliation(s)
- C Matsumoto
- Georgetown University Hospital Transplant Institute Center for Intestinal Rehabilitation and Transplantation, 3800 Reservoir Road NW, Washington, DC 20007, USA.
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Kato T, Gaynor JJ, Nishida S, Mittal N, Selvaggi G, Levi D, Moon J, Thompson J, Ruiz P, Madariaga J, Tzakis AG. Zoom endoscopic monitoring of small bowel allograft rejection. Surg Endosc 2006; 20:773-82. [PMID: 16544078 DOI: 10.1007/s00464-005-0331-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2005] [Accepted: 11/08/2005] [Indexed: 11/25/2022]
Abstract
BACKGROUND The small bowel has been successfully transplanted in patients with irreversible intestinal failure. This report aims to describe endoscopic monitoring of small bowel rejection. METHODS A magnification endoscope (zoom endoscope) was used in this study. In the first part of the study (October 1998 to March 2000, 271 endoscopy sessions), the specific endoscopic findings that correlated with rejection were determined. An analysis then was performed on data from the second period (March 2001 to November 2002, 499 sessions) to evaluate the zoom endoscope's accuracy in monitoring rejection. RESULTS Specific endoscopic findings of rejection found in the first period included background erythema, villous congestion, blunted villous tip, and shortened villous height. When the rejection was successfully treated, endoscopic appearance returned to normal. On the basis of these findings, five endoscopic criteria (villous shortening, villous blunting, background erythema, villous congestion, and mucosal friability) were used to score endoscopic sessions in the second period. Endoscopic diagnosis of rejection was compared with histology. Adult patients showed a sensitivity of 45%, a specificity of 98%, a positive predictive value of 82%, and a negative predictive value of 88%. In pediatric patients, these values were, respectively, 61%, 84%, 57%, and 86%. On 59 distinct occasions (30 in period 1 and 29 in period 2) in which the results were endoscopy negative yet biopsy positive (mild) for rejection, we elected not to treat these rejections on the basis of clinical evaluation, and 58 (98%) resolved without further therapy. CONCLUSIONS With the use of magnification, endoscopy is a useful tool for monitoring acute rejection in the small bowel allograft.
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Affiliation(s)
- T Kato
- Department of Surgery, University of Miami, School of Medicine, 1801 NW 9th Avenue, 5th Floor, Miami, FL 33136, USA.
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John M, Gondolesi G, Herold BC, Kaufman S, Fishbein T, Posada R. Impact of surveillance stool culture guided selection of antibiotics in the management of pediatric small bowel transplant recipients. Pediatr Transplant 2006; 10:198-204. [PMID: 16573607 DOI: 10.1111/j.1399-3046.2005.00424.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Surveillance stool cultures (SSC) have been used in immunocompromised populations to predict the organisms associated with invasive infections and aid in the selection of empiric antibiotic regimens. To evaluate the utility of this approach in pediatric small bowel transplant (SBT) recipients, we conducted a retrospective review of 33 patients who underwent SBT, 16 of whom had SSC done. In no case was the same organism isolated from SSC and subsequent blood, peritoneal fluid or wound cultures. In the first month post-transplantation, blood cultures were positive in 44% and 35% of patients that had and did not have SSC done, respectively (p = 0.73); peritoneal fluid cultures in 44% and 65% (p = 0.30); and wound cultures in 44% and 24% (p = 0.28). There were no significant differences among both groups in time to first infection, duration of ICU stay following SBT, graft survival or long-term patient survival. We conclude that SSC-guided antibiotic selection does not have a significant impact on the incidence of invasive infections in the first month following SBT or on specific indicators of patient outcome. This suggests that empiric antibiotic regimens should be selected based on clinical presentation and hospital flora and susceptibility patterns.
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Affiliation(s)
- Minnie John
- Department of Pediatrics, The Mount Sinai School of Medicine, New York, NY 10029, USA
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Fishbein TM, Matsumoto CS. Intestinal replacement therapy: timing and indications for referral of patients to an intestinal rehabilitation and transplant program. Gastroenterology 2006; 130:S147-51. [PMID: 16473063 DOI: 10.1053/j.gastro.2005.12.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2005] [Accepted: 09/21/2005] [Indexed: 12/02/2022]
Abstract
Current treatment options for patients suffering from intestinal insufficiency include all forms of intestinal replacement therapy (IRT). Parenteral nutrition has achieved extended success for the majority of patients requiring interval treatment, however, complications leading to failure of this treatment increases with the duration of therapy. There is currently no consensus as to the appropriate timing for transplantation of the intestine or the timing of referral for evaluation at a center experienced with this therapy. Certain patient characteristics warrant evaluation. Those patients with no jejunoileum who have guaranteed lifelong parenteral dependence, both adult and pediatric, should be immediately referred to a transplant center due to the high likelihood of the development of liver disease. Patients with metastatic infectious complications from catheter sepsis, patients with cholestasis seen intermittently with sepsis episodes, patients who are not successfully weaning and who demonstrate progressive thrombocytopenia, and patients with motility disorder experiencing deterioration should also warrant early referral to an intestinal rehabilitation and transplant program. The objective of evaluation is to maximize the opportunities for rehabilitation while not missing the critical window of opportunity for successful transplantation when needed. We favor an aggressive directed approach to rehabilitation, coupled with psychological preparation for both transplantations and other options. Early referral requires trust between the patient, referring physician, and the transplant team to assure that a rush to judgment will not lead to a premature transplant. The current wait list mortality is high, mandating early referral and listing with an approach aimed at maximizing both the success of gastrointestinal support, as well as of transplantation when necessary.
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Affiliation(s)
- Thomas M Fishbein
- Small Bowel & Pediatric Liver Transplantation, Georgetown University Hospital, Washington, DC 20007, USA.
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Harpaz N, Schiano T, Ruf AE, Shukla D, Tao Y, Fishbein TM, Sauter BV, Gondolesi GE. Early and frequent histological recurrence of Crohn's disease in small intestinal allografts. Transplantation 2006; 80:1667-70. [PMID: 16378058 DOI: 10.1097/01.tp.0000184621.63238.ec] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recurrence of Crohn's disease in small intestinal allografts, although rarely described, can cause serious morbidity and jeopardize graft survival among transplant recipients with Crohn's disease. However, systematic studies to determine the frequency, predictors, and clinical implications of recurrent Crohn's disease have not been reported METHODS We analyzed our transplant program's experience with small intestinal allografts in patients with Crohn's disease based on retrospective review of clinical and pathological records and corresponding pathology slides. RESULTS Of 67 patients undergoing 70 transplantations between 1998 and 2004, six adults (three males, three females; mean age 48.1 years) had Crohn's disease complicated by short gut syndrome and total parenteral nutrition failure. Four survivors surveyed endoscopically for a mean 29 (range, 20-40) months and underwent a mean 37 endoscopic examinations with biopsies (range, 31-44) while on maintenance immunosuppression. Despite absence of any endoscopic or clinical manifestations of Crohn's disease throughout this period, two patients had granulomatous enteritis characteristic of Crohn's disease in multiple biopsies, one patient in 8/44 examinations (18%) ranging from 34 days to 20 months postoperatively and the other in 6/32 examinations (19%) ranging from 20 days to 22 months postoperatively. No comparable changes occurred in 57 other patients without Crohn's disease followed endoscopically under the same protocol CONCLUSIONS Histological recurrence of Crohn's disease may occur in small intestinal allografts despite the absence of endoscopic and clinical disease manifestations. Such recurrences are probably not rare, may occur as early as 3 weeks after transplantation, and do not necessarily portend early clinical recurrence or mandate aggressive therapy to prevent allograft loss.
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Affiliation(s)
- Noam Harpaz
- Department of Pathology, The Mount Sinai Medical Center, New York, NY 10029, USA.
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Tahara K, Murakami T, Fujishiro J, Takahashi M, Inoue S, Hashizume K, Matsuno K, Kobayashi E. Regeneration of the rat neonatal intestine in transplantation. Ann Surg 2005; 242:124-32. [PMID: 15973110 PMCID: PMC1357713 DOI: 10.1097/01.sla.0000168089.64630.94] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Based on development of stem cell technology, newborn tissue, even undergoing cryopreservation, possesses promising potential as a donor source in the field of organ transplantation. However, the precise regeneration processes remains unclear. This study was designed to investigate the regenerative potential of newborn intestine with or without cryopreservation in the transplantation. METHODS Newborn rat intestines with or without cryopreservation were transplanted subcutaneously into the syngeneic host, and specimens were evaluated by histology, multiple immunostaining, and comprehensive gene expression analysis. RESULTS We determined that newborn rat intestine possessed regenerative potential in the syngeneic host even after cryopreservation, where angiogenesis was induced early in the submucosa with subsequent maturation in the crypts. Furthermore, newborn intestinal graft could facilitate the survival of maturation-incompetent 10-day-old graft that lacked regenerating activity (P < 0.01, n = 13). Tissue aggregates from the maturation-incompetent graft underwent reconstitution of their histologic configuration in the presence of newborn intestinal aggregates. Comprehensive gene expression analysis showed that 37 genes were preferentially up-regulated, while 19 genes were down-regulated in the regenerating 10-day-old graft (supported by the newborn graft). CONCLUSIONS Regeneration of newborn intestine is implicated in neo-angiogenesis in the host, and the newborn intestinal graft is capable of mediating the survival of the maturation-incompetent 10-day-old graft. Notwithstanding ethical and legal limitations in the clinic, these results may provide new insights into the regenerative role of newborn grafts.
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Affiliation(s)
- Kazunori Tahara
- Division of Organ Replacement Research, Center for Molecular Medicine, Jichi Medical School, Tochigi, Japan
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Selvaggi G, Gyamfi A, Kato T, Gelman B, Aggarwal S, Begliomini B, Bennett J, Nishida S, Tzakis AG. Analysis of vascular access in intestinal transplant recipients using the Miami classification from the VIIIth International Small Bowel Transplant Symposium. Transplantation 2005; 79:1639-43. [PMID: 15973163 DOI: 10.1097/01.tp.0000164317.38855.60] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Loss of vascular access in patients with intestinal failure is considered an indication for intestinal transplantation. Such patients often have one or more occluded vein sites. Venous access could be classified according to the number of occluded vessels, to facilitate pre- and postoperative management. METHODS At the VIIIth International Small Bowel Transplant Symposium in September 2003, a new classification of vascular access in patients who were candidates for bowel transplant was proposed. The classification was then applied to stratify all patients that underwent intestinal transplantation at the University of Miami between 1998 and 2003. Data were collected on Doppler ultrasonography, angiography, and vein angioplasty in such patients. RESULTS A total of 106 cases in 91 patients were included in the study. Based on Doppler ultrasound results, 51.9% of patients fell into class I (no thrombosed vessels), 21.7% were in class II (one occluded vessel, or positive risk factors for thrombosis), 24.5% were in class III (multiple thrombosed vessels), and 1.9% were in class IV (all vessels thrombosed). Fifteen percent of the patients required preoperative angiography to better evaluate venous access. Most of the patients that required angiography were in class III or IV, and 53.3% of patients requiring angiography needed additional venous angioplasty to achieve access. CONCLUSIONS All patients that are referred for intestinal transplantation should undergo preliminary mapping of their venous access by Doppler ultrasound and then be assigned to a vascular access class. Those patients with multiple thrombosed vessels (class III and above) should be strongly considered for additional angiographic evaluation.
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Affiliation(s)
- Gennaro Selvaggi
- Division of Liver and GI Transplantation, University of Miami School of Medicine, 1801 NW 9th Avenue, Ste 507, Miami, FL 33136, USA.
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Yu JR, Yan S, Liu XS, Wu YJ, Fu PF, Wu LH, Zheng SS. Attenuation of graft ischemia-reperfusion injury by urinary trypsin inhibitor in mouse intestinal transplantation. World J Gastroenterol 2005; 11:1605-9. [PMID: 15786535 PMCID: PMC4305939 DOI: 10.3748/wjg.v11.i11.1605] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: Ischemia/reperfusion (I/R) injury is one of the major obstacles for intestinal transplantation (ITx). Urinary trypsin inhibitor (Ulinastatin, UTI) suppresses proteases and stabilizes lysosomal membranes. We supposed that Ulinastatin would diminish I/R injury of intestinal graft.
METHODS: UTI- treated group and untreated control group were investigated by histological assessment at 1.5, 4, 24, and 72 h after ITx. Myeloperoxidase (MPO) activity was used as the activity of neutrophils, and malondialdehyde (MDA) was used as an index of lipid peroxidation. TNFα and i-NOS mRNA expression in graft tissue were measured by semi-quantitative RT-PCR. CD11b+ Gr1+ cells in graft lamina propria were analyzed by flow cytometry.
RESULTS: Histological scores of the graft showed that the tissue injury was markedly attenuated by UTI treatment at different time points after ITx, with reduced MPO and MDA value in the grafts. The expression of TNFα and i-NOS mRNA was profoundly inhibited, while the infiltration of CD11b+ Gr1+ cells into the intestinal graft was decreased in UTI group.
CONCLUSION: Urinary trypsin inhibitor attenuates I/R injury in mouse intestinal transplantation by reducing monocytes infiltration and down-regulation of TNFα and i-NOS mRNA expression.
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Affiliation(s)
- Ji-Ren Yu
- Department of Surgery, the First Affiliated Hospital, College of Medicine, Zhejiang University, Qingchun Road 79, Hangzhou 310003, Zhejiang Province, China.
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Abstract
After 4 decades of development, the American Gastroenterological Association in a medical position statement recently declared intestinal transplantation to be an acceptable therapy for patients suffering from intestinal failure. Improvements in surgical technique, immunosuppression, and treatment of rejection and infection have contributed to this advancement. Early referral and candidate selection have also been cited as key components to a successful transplantation. The evaluation period, including the referral process, is the cornerstone for this success. The purpose of this article is to present a detailed definition and analysis of the evaluation process. Criteria for listing with the United Network for Organ Sharing will also be discussed.
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Kato T, Gaynor JJ, Selvaggi G, Mittal N, Thompson J, McLaughlin GE, Nishida S, Moon J, Levi D, Madariaga J, Ruiz P, Tzakis A. Intestinal transplantation in children: a summary of clinical outcomes and prognostic factors in 108 patients from a single center. J Gastrointest Surg 2005; 9:75-89; discussion 89. [PMID: 15623448 DOI: 10.1016/j.gassur.2004.10.012] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We performed 124 intestinal transplants on 108 children (median age, 1.5 years) since 1994. Initial graft types included isolated intestine (I) (n=26), liver and intestine (LI) (n=26), multivisceral (MV) (n=50), and multivisceral without liver (MMV) (n=6). Four groups were defined by type of induction therapy: none, OKT3, or cyclophosphamide (August 1994-December 1997, n=25), early experience with daclizumab (January 1998-December 2000, n=26), recent experience with daclizumab (January 2001-April 2004, n=40), and Campath-1H (January 2001-April 2004, n=17). Actuarial patient survival at 1 year for groups 1-4 was 44%+/-10%, 54%+/-10%, 83%+/-6%, and 41%+/-12%, respectively, with group 3 having the most favorable survival (P=0.0004). Using Cox stepwise regression, the hazard rate of developing severe rejection was significantly higher in patients with transplant type I or LI (P=0.0002), with no difference between these groups (P=0.24) but a significantly higher rate for LI versus MV (P=0.005). Three factors associated with improved patient survival were recipient of MV or MMV (P=0.008), age at transplantation greater than 1 year (P=0.01), and use of daclizumab (P=0.0006). Cause-specific hazard analysis revealed a decreased rate of rejection-related mortality for recipients of MV or MMV (P=0.0007), whereas age greater than 1 year indicated a lower rate of infection-related mortality (P=0.0009). Pediatric intestinal transplantation provides an increasingly realistic chance of survival, particularly with the more recent use of daclizumab and multivisceral transplantation. A protective effect of multivisceral transplantation appears to exist with respect to the development of severe rejection.
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Affiliation(s)
- Tomoaki Kato
- Division of Transplantation, University of Miami, School of Medicine, Miami, Florida 33136, USA.
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Beckurts KTE, Stippel D, Schleimer K, Schäfer H, Benz C, Dienes HP, Hölscher AH. First case of isolated small bowel transplantation at the university of cologne: rejection-free course under quadruple immunosuppression and endoluminal monitoring with video-capsule. Transplant Proc 2004; 36:340-2. [PMID: 15050152 DOI: 10.1016/j.transproceed.2004.01.104] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Intestinal transplantation is the only curative form of treatment for fulminant short bowel syndrome. Results have been hampered by frequent rejection episodes as well as technical and infectious complications. We report the first case of complete small bowel transplantation performed at our institution. A 37-year-old male patient suffered from massive gut infarction due to a superior mesenteric artery embolus from a thrombus in the descending aorta resulting from hereditary protein S and C deficiency. The primary surgery resulted in a duodenocolostomy requiring total parenteral nutrition. The course was further complicated by multiple central line infections and pre-renal kidney failure induced by dehydration. After 17 months, we performed a cadaveric small bowel transplant using systemic venous drainage. The ileum was anastomosed end-to-end to the recipient ascending colon. The proximal jejunum was used to create a jejunostomy, with an end-to-side duodenojejunostomy. Immunosuppression consisted of a single-administration of antithymocyte globulin (ATG), tacrolimus, mycophenolate mofetil (MMF), and methylprednisolone given enterally from day 1. Biopsies of the upper jejunum showed no signs of rejection. The graft was monitored via capsule video endoscopy after 9 weeks and appeared normal. The patient was discharged on day 35, completely on an enteral diet and gaining weight with a good quality of life. Oral valganciclovir was given for the cytomegalovirus prophylaxis infection (donor-positive, recipient-negative constellation), with no clinical or serologic signs of infection. The early course after small bowel transplantation using a quadruple regimen was clinically successful. The use of video-capsules allows for noninvasive visual monitoring of bowel segments that cannot be reached endoscopically.
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Kellersmann R, Ulrichs K, Kellersmann A, Thiede A. Intragraft distribution of lymphocytes expressing β7 integrins after small bowel transplantation in mice. Transpl Immunol 2004; 13:249-58. [PMID: 15589737 DOI: 10.1016/j.trim.2004.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2004] [Accepted: 10/26/2004] [Indexed: 01/18/2023]
Abstract
Lymphocytes with activated beta7 integrins (alphaEbeta7 and alpha4beta7) contribute to inflammatory reactions in the small bowel. Since the selective recruitment of lymphocytes to the lymphoid compartments of the small bowel is controlled by distinct adhesion molecule interactions, a compartment-dependent use of beta7 integrins may influence the rejection response within intestinal transplants. To further delineate the nature of beta7 integrin-mediated graft infiltration, we analysed their expression on T lymphocytes in the heterotopically transplanted small bowel of BALB/c and C57BL/6 mice. Lymphocytes isolated from the epithelium, lamina propria (LP), Peyer's patches (PP), and mesenteric lymph nodes (MLN) were analysed by three-color fluorescence flow cytometry using monoclonal antibodies (mAb) to integrin the subunits, lymphocyte markers, and MHC I of the donor and recipient strains. On postoperative day 5 (POD) after allogeneic small bowel transplantation (SBT), 43% of intraepithelial lymphocytes (IEL) and 63% of LP, 93% of MLN, and 93% of PP lymphocytes were of host origin. In the MLN and PP of allografts, a major infiltrating lymphocyte population consisted of CD8+ cells with increased expression of alpha4beta7 and decreased expression of L-selectin, an adhesion molecule profile characteristic of intestinal effector cell phenotypes. An increase in alpha4beta7 levels was also found on CD8+ host lymphocytes in the LP. The integrin profile of a number of host IEL suggests an ongoing transition from the phenotype of graft infiltrating lymphocytes with high levels of alpha4beta7 and low levels of alphaepsilonbeta7 to that of resident IEL with high levels of alphaepsilonbeta7 and low levels of alpha4beta7. The importance of beta7-mediated lymphocyte trafficking to the graft is attested by the significant reduction in the host lymphocyte population in the LP, PP, and epithelium following the administration of a beta7-blocking mAb to allograft recipients. In conclusion, while the infiltration patterns of lymphocytes may vary between the lymphoid compartments of intestinal allografts, host CD8+ lymphocytes with high levels of alpha4beta7 constitute a major effector cell population that affects the entire graft.
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Affiliation(s)
- Richard Kellersmann
- Experimental Transplantation Immunology, Department of Surgery, University of Würzburg, Oberdürrbacher Str.6, 97080 Würzburg, Germany.
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Abstract
The management of patients with intestinal failure due to short bowel syndrome is complex, requiring a comprehensive approach that frequently necessitates long-term, if not life-long, use of parenteral nutrition. Despite tremendous advances in the provision of parenteral nutrition over the past three decades, which have allowed significant improvements in the survival and quality of life of these patients, this mode of nutritional support carries with it significant risks to the patient, is very costly, and ultimately, does not attempt to improve the function of the remaining bowel. Intestinal rehabilitation refers to the process of restoring enteral autonomy, and thus, allowing freedom from parenteral nutrition, usually by means of dietary, medical, and occasionally, surgical strategies. While recent investigations have focused on the use of trophic substances to increase the absorptive function of the remaining gut, whether intestinal rehabilitation occurs as a consequence of enhanced bowel adaptation or is simply a result of an optimized, comprehensive approach to the care of these patients remains unclear. In Part 1 of this review, we provided an overview of short bowel syndrome and pathophysiological considerations related to the remaining bowel anatomy in these patients. We also reviewed intestinal adaptation and factors that may enhance the adaptive process, focusing on evidence derived from animal studies. In Part 2, relevant data on the development of intestinal adaptation in humans are reviewed as is the general management of short bowel syndrome. Lastly, the potential benefits of a multidisciplinary intestinal rehabilitation program in the care of these patients are also discussed.
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Affiliation(s)
- John K DiBaise
- Department of Internal Medicine, University of Nebraska Medical Center, 982000 Nebraska Medical Center, Omaha, NE 68198-2000, USA
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Affiliation(s)
- Cheryl E Gariepy
- Department of Pediatrics and Communicable Diseases, Division of Gastroenterology, University of Michigan, 1150 W Medical Center Dr, A520 MSRBI, Ann Arbor, MI 48109-0656, USA.
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