1
|
Wichmann D, Nadalin S, Schweizer U, Solaß W, Steidle C, Stüker D, Lange J, Werner CR, Königsrainer A, Quante M. Evaluating the diagnostic value of zoom endoscopic surveillance compared to routine biopsy after intestinal transplantation. Dig Liver Dis 2022; 54:385-390. [PMID: 35090824 DOI: 10.1016/j.dld.2021.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/28/2021] [Accepted: 12/29/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND After intestinal transplantation, close allograft monitoring especially during the early postoperative period is crucial since the intestine is a highly immunogenic organ. Current protocols are based on endoscopic and histologic examination with the latter one being linked to the risk of bleeding and perforation. AIMS Evaluation of the diagnostic value of endoscopy utilizing magnification to predict acute cellular rejection compared to routine allograft biopsies. METHODS Fourteen patients underwent the protocol with longitudinal zoom endoscopic and histological graft monitoring during the first year after transplantation. The intestinal mucosa was analyzed during endoscopy utilizing the SASAKI score while a minimum of two biopsies were taken during each examination. A new graduation of severity for acute cellular rejection based on the findings of the SASAKI score is established. RESULTS Endoscopic findings of 385 examinations and more than 1000 intestinal allograft biopsies were analyzed. A total of 7 acute cellular rejection episodes in 6/14 patients occurred. Allograft endoscopy was able to diagnose ACR with a sensitivity of 76% and a specificity of 82%. CONCLUSIONS Our results will be critical for refining protocols for allograft monitoring after intestinal transplantation thus paving the way towards less invasive measures.
Collapse
Affiliation(s)
- Dörte Wichmann
- Department of General, Visceral and Transplantation Surgery, University Hospital Tübingen, 72076, Tübingen, Germany.
| | - Silvio Nadalin
- Department of General, Visceral and Transplantation Surgery, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Ulrich Schweizer
- Department of General, Visceral and Transplantation Surgery, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Wiebke Solaß
- Department of Pathology, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Christoph Steidle
- Department of General, Visceral and Transplantation Surgery, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Dietmar Stüker
- Department of General, Visceral and Transplantation Surgery, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Jessica Lange
- Department of Surgery, Filderklinik 70794, Filderstadt-Bonlanden, Germany
| | - Christoph R Werner
- Department of Internal Medicine I, Gastroenterology, Infectiology, Gastrointestinal Oncology, Hepatology and Geriatrics, University Hospital Tübingen, 72076 Tübingen, Germany
| | - Alfred Königsrainer
- Department of General, Visceral and Transplantation Surgery, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Markus Quante
- Department of General, Visceral and Transplantation Surgery, University Hospital Tübingen, 72076, Tübingen, Germany
| |
Collapse
|
2
|
Abstract
The growing population of intestinal transplant recipients present a unique challenge to the gastroenterologists responsible for their support and evaluation. Improvements in patient and graft survival are largely attributed to surgical advancements, refined antirejection therapy, and enhanced endoscopic surveillance protocols that better perceive rejection and other complications. This article reviews the endoscopic management and interventions provided for transplant recipients at the University of Illinois Hospital with complications, such as acute rejection, ischemia, bleeding, fistula, post-transplant lymphoproliferative disorder, and gastroparesis. Further research is needed on promising strategies currently used for related diseases to treat and sustain the intestinal graft.
Collapse
Affiliation(s)
- Robert E Carroll
- Department of Medicine, University of Illinois at Chicago, Chicago Veterans Administration Medical Center (West Side Division), 840 South Wood Street (M/C 787), Chicago, IL 60612, USA.
| |
Collapse
|
3
|
Guo M, Li Y, Wang Z, Wu B, Wang J, Li J. Morphological Adaptation in Adult Short Bowel Syndrome Undergoing Intestinal Rehabilitation. J INVEST SURG 2013; 26:1-5. [DOI: 10.3109/08941939.2011.652728] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
4
|
Setty S, Wu SJ, Bogard A, Chejfec G, Carroll R, Benedetti E, John E, Setty A. Application of the paraboloidal model to assess mucosal changes following segmental intestinal transplantation in children. Transplant Proc 2011; 43:1823-30. [PMID: 21693285 DOI: 10.1016/j.transproceed.2011.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2010] [Accepted: 03/01/2011] [Indexed: 10/18/2022]
Abstract
Segmental living related small intestinal transplantation (LRSITx) is a therapeutic option for conditions that present with short gut syndromes. Recovery of small intestinal mucosa after transplantation is critical to function. We examined the posttransplant mucosal changes to understand the absorptive capabilities of transplanted small intestine. The study of human subjects is constrained by limited biopsy material; therefore, we developed a technique of villus area measurement by extrapolation from two-dimensional surgical biopsy images. Using a detailed model of the villus as the gold standard, two simpler models (cylindrical and paraboloid) were tested. Comparisons with the accurate measurement revealed that the cylinder model does not compare well in early posttransplant biopsies. The paraboloid function developed in this article worked very well under all conditions. The simplicity of the paraboloid model and its robustness made high-quality estimates of the absorptive surface area from abundant data relatively easy. The remodeling expected in the initial stages of growth was also captured by this model. Time-dependent villus growth curves were obtained for transplanted bowel. Serial biopsies showed an initial "reconstruction" dip around 2 weeks after transplant, followed by continuous growth of villus surface area. An eventual plateau resulted at an average of 6 months after transplant. This growth of villi was shown to parallel the improved absorption of electrolytes, amino acids, and water.
Collapse
Affiliation(s)
- S Setty
- Department of Pathology, University of Illinois Medical Center at Chicago, Illinois, USA
| | | | | | | | | | | | | | | |
Collapse
|
5
|
Yoshimura N, Okajima H, Ushigome H, Sakamoto S, Fujiki M, Okamoto M. Current status of organ transplantation in Japan and worldwide. Surg Today 2010; 40:514-25. [PMID: 20496132 DOI: 10.1007/s00595-009-4214-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Accepted: 11/09/2009] [Indexed: 12/19/2022]
Abstract
Recent advances in immunosuppressant therapy have dramatically reduced the frequency of acute rejection of organ transplants. Subsequently, the short-term graft survival rate has been improved, and ABO blood type-incompatible and existing anti-HLA antibody-positive kidney transplantation has been enabled, which has increased the availability of living kidney donors. Japan has a unique history and strategies of liver transplantation (LT) for various liver diseases. The outcomes of living donor liver transplantation (LDLT) in Japan is comparable to that of deceased donor liver transplantation (DDLT) in Western countries despite the relatively short history of LT. The main disadvantage of LT in Japan is donor shortage mainly due to the small number of available deceased donors. There are some disadvantages with LDLT in autoimmune liver diseases because of the dependence on blood relative donors. The first brain-dead pancreas transplantation (PTx) was performed in 2000. Since that time, 42 brain-dead PTx, 2 non-heart beating PTx, and 14 living donor PTx had been performed by the end of 2007. One of the 44 recipients of deceased donor PTx died of unknown causes 11 months after transplantation. Although most of the deceased donors in Japan were marginal and their condition was not favorable, the results of these cases were comparable to those of Western countries. Fourteen intestinal transplantations (ITx) had been performed by the end of 2007 in four transplant centers. There were 3 deceased donor and 11 live donor transplants. The original diseases included short bowel syndrome (n = 6), intestinal function disorder (n = 6), and retransplantation (n = 2). The graft and patient survival rate are 60% and 69%, respectively. Eight recipients survived and stopped parenteral nutrition with full-functioning grafts. Amendment of the Japanese law for the utilization of deceased donors should increase the number available donors in the future.
Collapse
Affiliation(s)
- Norio Yoshimura
- Department of Organ Transplant and Regenerative Surgery, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, 465 Hirokoji Kawaramachi, Kamigyo-ku, Kyoto, 602-0841, Japan
| | | | | | | | | | | |
Collapse
|
6
|
Watanabe T, Hoshino K, Tanabe M, Morikawa Y, Kawachi S, Wakabayashi G, Shimazu M, Kitajima M. Correlation of motility and neuronal integrity with a focus on the grade of intestinal allograft rejection. Am J Transplant 2008; 8:529-36. [PMID: 18294149 DOI: 10.1111/j.1600-6143.2007.02115.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Intestinal graft motility after small bowel transplantation (SBT) is poorly characterized. The aim of this study was to compare motor patterns with myenteric neuronal cell population as a parameter of graft viability at various degrees of acute cellular rejection (ACR). Three grades of ACR were achieved in orthotopic allografts. Syngeneic transplants and allografts with immunosuppression served as controls. Motor activities were recorded using strain gauge force transducers and analyzed visually. Quantifications of myenteric neurons in whole mounts of intestinal grafts were used to evaluate neuronal population. A typical migrating motor complex (MMC) was found in syngeneic and allogenic transplants with immunosuppression. A high prevalence of discrete clustered contractions (DCC) and nonpropagating contractions (NPC) without MMC was seen in moderately and severely rejected allografts. Neuronal cell loss in the allografts, which could be one of the causes of motor dysfunction, was noted in moderate rejection (19.3%) and progressed until severe rejection (60.1%). Monitoring motility patterns in SBT could be an effective tool for assessing intestinal rejection. Allograft dysmotility, such as absence of MMC and high prevalence of DCC or NPC, could be useful markers of progression of acute rejection and help guide treatment decisions.
Collapse
Affiliation(s)
- T Watanabe
- Department of Surgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | | | | | | | | | | | | | | |
Collapse
|
7
|
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.
Collapse
Affiliation(s)
- Alfred Königsrainer
- Department of General and Transplant Surgery, Innsbruck Medical University Hospital, Innsbruck, Austria.
| | | | | | | | | | | | | | | |
Collapse
|
8
|
Matsuura T, Taguchi T, Hayashida M, Ogita K, Takada N, Nishimoto Y, Taguchi S, Uesugi T, Kondo T, Hirose R, Suita S. The influence of rejection on graft motility after intestinal transplantation in swine: the possibility of using this method for the real-time monitoring of acute cellular rejection. J Pediatr Surg 2007; 42:1377-85. [PMID: 17706500 DOI: 10.1016/j.jpedsurg.2007.03.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND We have previously reported that rejected allografts show dysmotility, which can be detected by real-time monitoring in swine. We examined the correlation between the motility and the mucosal histology to detect rejection at an early stage by real-time monitoring. METHODS Intestinal transplantation was performed orthotopically using FK506. The distal segment of the allograft measuring about 20 cm was isolated and exteriorized as "Thiry-Vella" stoma for biopsies. Strain-gage force transducers were attached on a graft for the real-time monitoring of graft motility. The pigs without intestinal transplantation were used as controls (C). The rejection was classified into 4 groups based on the histologic findings: nonrejection, mild rejection, moderate rejection, and severe rejection. Migrating motor complex (MMC) phase 3 was estimated by the following parameters: duration, amplitude, interval, motility index, velocity, and frequency of the propagation. RESULTS In the nonrejection group, all parameters were almost the same as in C group. In contrast, in the moderate rejection and severe rejection groups, most of the parameters were significantly lower than those in the C group. In the mild rejection group, the contractility of the MMC was not significantly altered, but the frequency of the propagation decreased significantly. CONCLUSIONS The graft motility detected by the real-time strain-gage method correlated closely to the grade of mucosal histology. This method is therefore considered to be useful for detecting rejection at an early stage by examining the frequency of MMC propagation.
Collapse
Affiliation(s)
- Toshiharu Matsuura
- Department of Pediatric Surgery, Reproductive and Developmental Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Selvaggi G, Gaynor JJ, Moon J, Kato T, Thompson J, Nishida S, Levi D, Ruiz P, Cantwell P, Tzakis AG. Analysis of acute cellular rejection episodes in recipients of primary intestinal transplantation: a single center, 11-year experience. Am J Transplant 2007; 7:1249-57. [PMID: 17359506 DOI: 10.1111/j.1600-6143.2007.01755.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Intestinal transplantation has evolved over the years with major improvements in patient and graft survival. Acute cellular rejection of the intestine, however, still remains one of the most challenging aspects of postoperative management. We analyzed retrospectively collected data from 209 recipients of primary intestinal grafts at our institution over the past 11 years. A total of 290 episodes of biopsy-proven rejection requiring clinical treatment were analyzed. Rejection episodes doubled in length, on average, with each increasing grade (mild, moderate, severe). We observed increased incidence of overall rejection and particularly severe rejection in recipients of isolated intestinal and liver-intestine grafts in comparison with multivisceral grafts. Two rejection history variables had a significant negative impact on graft survival: the occurrence of a severe rejection episode and a rejection episode lasting >or=21 days. The lower incidence rate of severe rejection in recipients of multivisceral grafts might be due to a combination of increased donor lymphatic tissue and larger load of donor-derived immune competent cells present in the graft. The development of more effective monitoring and treatment protocols to prevent the occurrence of severe and/or lengthy rejection episodes is of critical importance for intestinal graft survival.
Collapse
Affiliation(s)
- G Selvaggi
- Division of Liver and GI Transplantation, University of Miami Miller School of Medicine, Miami, FL, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
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.
Collapse
Affiliation(s)
- Felix Braun
- Klinik für Allgemeine Chirurgie und Thoraxchirurgie, Zentrum Chirurgie, Universität Schleswig-Holstein, Campus Kiel, Arnold-Heller-Strasse 7, 24105 Kiel, Germany
| | | | | |
Collapse
|
11
|
Tzakis AG, Kato T, Nishida S, Levi DM, DeFaria W, Selvaggi G, Weppler D, Moon J, Madariaga JR, David AI, Gaynor JJ, Thompson J, Hernandez E, Tuteja S, Tryphonopoulos P, Ruiz P. The Miami Experience With Almost 100 Multivisceral Transplants. Transplant Proc 2006; 38:1681-2. [PMID: 16908245 DOI: 10.1016/j.transproceed.2006.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
We report our experience with 98 patients who received primary multivisceral transplantations. Three eras can be distinguished based on the evolution of technique, immunosuppression, and monitoring: August 1994 to December 1997 (first era); January 1998 to December 2000 (second era); and January 2001 to present (third era). Sixteen patients were transplanted during the first era, 18 during the second era, and 64 during the third era. Fifty-three patients are alive with a median follow-up of 37.5 months (range: 1 to 116 months). The leading cause of mortality was infection (n = 17), followed by rejection (n = 6). Seven patients required retransplantation and five of them subsequently died. The estimated 3-year survival was 25% +/- 11% for era 1; 44% +/- 12% for era 2; and 58% +/- 7% for era 3. Additionally, 45.3% (29/64) of patients in the third era never developed rejection versus 23.5% (8/34) of patients in the first two eras combined. The percentage of patients who developed a moderate or severe rejection was significantly less in the third era compared with the first two eras combined, 31.6% (20/64) versus 67.6% (23/34). A comparison of the hazard rate of developing severe rejection showed a protective effect of the multivisceral graft (P = .0001). In conclusion, multivisceral transplantation is indicated for patients with short bowel syndrome and extended abdominal catastrophies. Evolution in surgical techniques, immunosuppression, and monitoring have improved patient survival, which is now similar to that of other complex solid organ transplants.
Collapse
Affiliation(s)
- A G Tzakis
- Department of Surgery, University of Miami Miller School of Medicine, 1801 NW 9th Avenue, Miami, FL 33136, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
|
13
|
Gaynor JJ, Kato T, Selvaggi G, Moon JI, Levi DM, Nishida S, Madariaga JR, Weppler D, Ruiz P, Tzakis AG. The Importance of Analyzing Graft and Patient Survival by Cause of Failure: An Example Using Pediatric Small Intestine Transplant Data. Transplantation 2006; 81:1133-40. [PMID: 16641598 DOI: 10.1097/01.tp.0000205754.58604.a8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although graft and patient survival are vital in reporting overall results of clinical transplant studies, these outcomes do not account for distinct types of graft failure and death, which clearly exist in pediatric small intestine transplantation (Itx). The use of a cause-specific hazard (CSH) approach may provide more precise identification and thus greater insight as to why certain factors are prognostically important. METHODS Among 119 pediatric patients who received primary Itx at our center since 1994, Cox model stepwise regression analyses were performed to identify prognostic factors for the following CSH rates: intestinal graft failure (IGF)/death due to rejection, death due to infection not triggered by IGF, and intestinal graft loss/death due to other causes. RESULTS Two factors were associated with a significantly higher rate of developing IGF due to rejection (23 such failures): receiving an isolated intestine or liver-intestine transplant (P=0.00001) and receiving no induction agent (P=0.006). Conversely, age at transplant <1 year was the single factor associated with a significantly higher death rate due to infection (P=0.0005) (21 such deaths). Two characteristics were associated with a significantly higher death rate due to other causes: being in the hospital pretransplant (P=0.007) and not receiving daclizumab induction therapy (P=0.02) (24 such deaths). Although these four factors (transplant type/age/hospital status/induction therapy) were, for the most part, associated with graft/patient survival, the CSH analysis more precisely identified their prognostic value and achieved greater statistical power. CONCLUSIONS A CSH approach should be used in conjunction with overall outcome analyses.
Collapse
Affiliation(s)
- Jeffrey J Gaynor
- Department of Surgery, University of Miami School of Medicine, Miami, FL33101, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
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.
Collapse
Affiliation(s)
- T Kato
- Department of Surgery, University of Miami, School of Medicine, 1801 NW 9th Avenue, 5th Floor, Miami, FL 33136, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Tzakis AG, Kato T, Levi DM, Defaria W, Selvaggi G, Weppler D, Nishida S, Moon J, Madariaga JR, David AI, Gaynor JJ, Thompson J, Hernandez E, Martinez E, Cantwell GP, Augenstein JS, Gyamfi A, Pretto EA, Dowdy L, Tryphonopoulos P, Ruiz P. 100 multivisceral transplants at a single center. Ann Surg 2005; 242:480-90; discussion 491-3. [PMID: 16192808 PMCID: PMC1402343 DOI: 10.1097/01.sla.0000183347.61361.7a] [Citation(s) in RCA: 203] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The objective of this study was to summarize the evolution of multivisceral transplantation over a decade of experience and evaluate its current status. SUMMARY BACKGROUND DATA Multivisceral transplantation can be valuable for the treatment of patients with massive abdominal catastrophes. Its major limitations have been technical and rejection of the intestinal graft. METHODS This study consisted of an outcome analysis of 98 consecutive patients who received multivisceral transplantation at our institution. This represents the largest single center experience to date. RESULTS The most common diseases in our population before transplant were intestinal gastroschisis and intestinal dysmotility syndromes in children, and mesenteric thrombosis and trauma in adults. Kaplan Meier estimated patient and graft survivals for all cases were 65% and 63% at 1 year, 49% and 47% at 3 years, and 49% and 47% at 5 years. Factors that adversely influenced patient survival included transplant before 1998 (P = 0.01), being hospitalized at the time of transplant (P = 0.05), and being a child who received Campath-1H induction (P = 0.03). Among 37 patients who had none of these 3 factors (15 adults and 22 children), estimated 1- and 3-year survivals were 89% and 71%, respectively. Patients transplanted since 2001 had significantly less moderate and severe rejections (31.6% vs 67.6%, P = 0.0005) with almost half of these patients never developing rejection. CONCLUSIONS Multivisceral transplantation is now an effective treatment of patients with complex abdominal pathology. The incidences of serious acute rejection and patient survival have improved in the most recent experience. Our results show that the multivisceral graft seems to facilitate engraftment of transplanted organs and raises the possibility that there is a degree of immunologic protection afforded by this procedure.
Collapse
Affiliation(s)
- Andreas G Tzakis
- Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida 33136, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
|
17
|
Affiliation(s)
- Thomas M Fishbein
- Department of Surgery, Mount Sinai School of Medicine, New York, New York 10029, USA.
| | | | | |
Collapse
|
18
|
Ding J, Guo CC, Li CN, Sun AH, Guo XG, Miao JY, Pan BR. Postoperative endoscopic surveillance of human living-donor small bowel transplantations. World J Gastroenterol 2003; 9:595-8. [PMID: 12632525 PMCID: PMC4621589 DOI: 10.3748/wjg.v9.i3.595] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the significance of endoscopic surveillance in the diagnosis of acute rejection after human living-donor small bowel transplantations.
METHODS: Endoscopic surveillance was performed through the ileostomy after human living-donor small bowel transplantations. The intestinal mucosa was observed and biopsies were performed for pathological observations.
RESULTS: Acute rejection was diagnosed in time by endoscopic surveillance. The endoscopic and pathological manifestations of acute rejection were described.
CONCLUSION: Endoscopic surveillance and biopsy are reliable methods to diagnose the acute rejection after human living-donor small bowel transplantations.
Collapse
Affiliation(s)
- Jie Ding
- Institute of Digestive Disease, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, Shaanxi Province, China.
| | | | | | | | | | | | | |
Collapse
|
19
|
Kato T, Mittal N, Nishida S, Levi D, Yamashiki N, Miller B, Gonzalez M, Ruiz P, Madariaga J, Nery J, Gelman B, Thompson J, Gyamfi A, Tzakis A. The role of intestinal transplantation in the management of babies with extensive gut resections. J Pediatr Surg 2003; 38:145-9. [PMID: 12596093 DOI: 10.1053/jpsu.2003.50033] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND/PURPOSE Modern neonatal care, surgical treatment, and total parenteral nutrition (TPN) have improved survival rate for babies with extensive gut resections. The authors examined the role of intestinal transplantation in the treatment of these patients. METHODS The authors reviewed all pediatric intestinal transplants performed for short bowel syndrome at our center (70 transplants performed between Aug 1994 and Feb 2002). Factors affecting patient survival were analyzed. RESULTS Older patient age at the time of transplant was a significant factor favorably affecting patient survival (P =.031). Trends toward better survival rates were observed in those transplants performed more recently (P =.063), in those patients with greater body weight (P =.084), in those not hospitalized at the time of transplant (P =.14), and in those without concomitant liver failure (P =.12). Three-year survival rate for patients greater than age 2 years and without liver failure was 90%. However, 32% of our recipients underwent transplant at age less than one year, and most in this group (75%) had concomitant liver failure. CONCLUSIONS For babies with irreversible intestinal failure, intestinal transplantation is a life-saving option. Results, which have recently improved, are best when transplantation compliments more conservative surgical treatments and TPN. However, there is a subset of patients who have liver disease early requiring urgent transplant.
Collapse
Affiliation(s)
- Tomoaki Kato
- Division of Liver and GI Transplant, and Department of Anesthesia, University of Miami, School of Medicine, Miami, FL, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Berney T, Kato T, Nishida S, Tector AJ, Mittal NK, Madariaga J, Nery JR, Cantwell GP, Ruiz P, Tzakis AG. Portal versus systemic drainage of small bowel allografts: comparative assessment of survival, function, rejection, and bacterial translocation. J Am Coll Surg 2002; 195:804-13. [PMID: 12495313 DOI: 10.1016/s1072-7515(02)01482-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Portal venous drainage of small bowel grafts is theoretically more physiologic than systemic drainage, but is technically more demanding. Comparisons in animal models have not demonstrated a clear advantage of one technique over the other, but clinical data are lacking. STUDY DESIGN Clinical records of 36 patients who underwent 37 small bowel transplantation procedures from January 1995 to August 2001 were reviewed. Portal drainage was performed in 19 patients (PD group). Systemic drainage was performed in 18 patients (SD group). Median followup was 531 days. RESULTS PD and SD patients had similar ICU stays (median 7 versus 9 days) and endotracheal intubation durations (median 3 versus 5 days). All current survivors, with the exception of one patient in each group, are independent from parenteral nutrition. Liver function tests were similar in both groups. There was a twofold increase in tacrolimus dosage in the PD group to achieve similar trough levels indicating a "first-pass" hepatic clearance effect. Cumulative incidence of acute rejection episodes and OKT3-requiring rejection episodes were similar in both groups. To the contrary, a lower incidence of gram-negative rods of Enterococcus sp. in blood or bronchoalveolar lavage suggested that the clearance of translocated intestinal bacteria was more efficient in the PD group. Graft and patient survival rates were similar in both groups. CONCLUSIONS Systemic venous drainage of small bowel transplants is a dependable technique, associated with similar results as portal venous drainage, in terms of overall mortality, morbidity, rejection, function, and patient and graft survival. But attention should be paid to an impaired clearance of intestinal bacterial translocation after systemic drainage.
Collapse
Affiliation(s)
- Thierry Berney
- Liver/Gastrointestinal Transplantation, Department of Surgery, University of Miami School of Medicine, Miami, FL 33136, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Kato T, Nishida S, Mittal N, Levi D, Nery J, Madariaga J, Thompson J, Weppler D, Ruiz P, Tzakis A. Intestinal transplantation at the University of Miami. Transplant Proc 2002; 34:868. [PMID: 12034213 DOI: 10.1016/s0041-1345(02)02646-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- T Kato
- University of Miami School of Medicine, Miami, Florida 33136, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Sasaki T, Hasegawa T, Nakai H, Kimura T, Okada A, Musiake S, Doi R. Zoom endoscopic evaluation of rejection in living-related small bowel transplantation. Transplantation 2002; 73:560-4. [PMID: 11889430 DOI: 10.1097/00007890-200202270-00013] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND This study evaluated zoom endoscopic findings according to four components in comparison with the histologic findings of acute cellular rejection (ACR) in a living-related small bowel transplantation (SBTx) patient. METHODS A 16-year-old boy with microvillus inclusion disease underwent SBTx with a 150-cm-long ileal graft from a blood-identical living-related donor. The endoscope was inserted into the distal stoma of the graft, and the mucosal architecture was observed under zoom. The observed findings were expressed by the following four components and graded as 0 to 2: H, homogeneity of mucosal change, minimal (H-0), patchy (H-1), diffuse (H-2); V, appearance of villi, stringlike (V-0), tonguelike (V-1), domelike (V-2); W, widening of crypt area, narrow (W-0), slightly widened within a width of one villus (W-1), markedly widened beyond a width of one villus (W-2); E, erythema in crypt area: no redness (E-0), sporadic erythema (E-1), diffuse erythema (E-2). RESULTS Histologic ACR was grade 0 in 27, grade 1 in 6, grade 2 in 3, and grade 3 in 0 occasions during 11 months after SBTx. In grade 0, 1, and 2 histology, H-0/H-1/H-2 was 85.2%/14.8%/0%, 33.3%/66.7%/0%, and 0%/100%/0%, respectively, with a significant difference among the groups by grade (P<0.05). V-0/V-1/V-2 was 48.1%/51.9%/0%, 0%/100%/0%, and 0%/66.7%/33.3% (P<0.05), W-0/W-1/W-2 was 85.2%/14.8%/0%, 0%/100%/0%, and 0%/66.7%/33.3% (P<0.05), and E-0/E-1/E-2 was 100%/0%/0%, 66.7%/33.3%/0%, and 0%/100%/0% (P<0.05), respectively. CONCLUSION Zoom endoscopic findings, graded on four components, may reflect the histologic severity of ACR and minimize the performance of biopsies in SBTx.
Collapse
Affiliation(s)
- Takashi Sasaki
- Departments of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | | | | | | | | | | | | |
Collapse
|
23
|
Abstract
The surgeon is invariably the primary specialist involved in managing patients with short bowel syndrome. Because of this they will play an important role in co-ordinating the management of these patients. The principal aims at the initial surgery are to preserve life, then to preserve gut length, and maintain its continuity. In the immediate postoperative period, there needs to be a balance between keeping the patient alive through the use of TPN and antisecretory agents and promoting gut adaptation with the use of oral nutrition. If the gut fails to adapt during this period, then the patient may require therapy with more specific agents to promote gut adaptation such as growth factors and glutamine. If following this, the patient still has a short gut syndrome, then the principal options remain either long term TPN, or intestinal transplantation which remains a difficult and challenging procedure with a high mortality and morbidity due to rejection.
Collapse
Affiliation(s)
- Cameron F E Platell
- Department of Surgery, The University of Western Australia, Perth, Australia.
| | | | | | | |
Collapse
|
24
|
Pirenne J, Koshiba T, Coosemans W, Herman J, Van Damme-Lombaerts R. Recent advances and future prospects in intestinal and multi-visceral transplantation. Pediatr Transplant 2001; 5:452-6. [PMID: 11737771 DOI: 10.1034/j.1399-3046.2001.t01-2-00025.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
From an experimental procedure, intestinal transplantation (ITx) has evolved over the last 10 yr into a treatment option for patients suffering from short bowel syndrome and who develop life-threatening complications from total parenteral nutrition (TPN) (e.g. liver dysfunction, line sepsis, shortage of venous access, etc.). One-year survival rates are approximately 70% and thus similar to lung Tx. However, the intestine remains the most challenging abdominal organ to transplant. This is because of the severe immune response (mostly rejection) that is produced, and therefore the need for profound immunosuppression with its attendant complications (sepsis, lymphoma, direct drug toxicity). Unlike other organs, graft loss as a result of acute rejection can occur late after transplantation (more than 1 yr post-transplant). With regard to the actual immunosuppressive regimens, considerable experience in patient management is required to optimize outcome of those complex transplants, which are permanently at risk of rejection and infection. ITx remains an unfinished product, and the application of ITx to patients doing well on TPN warrants further research in the understanding of the rejection process, in the development of less toxic and more efficient immunosuppressive protocols, and in the development of immunomodulatory strategies, to better control rejection and thereby reduce the need for immunosuppression.
Collapse
Affiliation(s)
- J Pirenne
- Abdominal Transplant Surgery and Pediatric Transplantation, University Hospitals Gasthuisberg, Catholic University Leuven, Leuven, Belgium.
| | | | | | | | | |
Collapse
|
25
|
Abstract
Small bowel transplantation has become the treatment of choice for patients with chronic gut failure whose illness cannot be maintained on home parenteral nutrition. Outcomes have improved as a result of refinements in patient selection, surgical techniques, and the prevention, diagnosis, and treatment of graft rejection. Early listing is important because of the shortage of organ donors. Rejection rates are still 50% or more, despite the use of potent immune suppression. Sepsis rates are also higher for patients who have had small bowel transplantation than for those who have received other organs because of bacterial translocation from the gut secondary to preservation injury and graft rejection. Graft and patient survival rates after small bowel transplantation are comparable to rates after lung transplantation. Successful transplant recipients resume unrestricted oral diets.
Collapse
Affiliation(s)
- A Ghanekar
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | |
Collapse
|
26
|
Chatzipetrou MA, Tzakis AG, Pinna AD, Kato T, Misiakos EP, Tsaroucha AK, Weppler D, Ruiz P, Berho M, Fishbein T, Conn HO, Ricordi C. Intestinal transplantation for the treatment of desmoid tumors associated with familial adenomatous polyposis. Surgery 2001; 129:277-81. [PMID: 11231455 DOI: 10.1067/msy.2001.110770] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Desmoid tumors associated with familial adenomatous polyposis (FAP) are locally invasive. Often occurring in the mesentery of the intestine, they sometimes recur after resection. Complications can include intestinal failure and dependence on parenteral nutrition. We describe 9 patients who underwent intestinal transplantation for the treatment of desmoid tumors associated with FAP. METHODS Records of patients undergoing intestinal transplantation for desmoid tumors at 2 transplant centers were reviewed for patient age, sex, type of graft, procedure date, tumor site, desmoid complications, medications, extracolonic manifestations, status at follow-up, and length of survival. RESULTS Nine patients with FAP and intestinal failure caused by desmoid tumors were treated with isolated intestinal (n = 6), multivisceral (n = 2), or combined liver-intestinal transplantation (n = 1). Desmoid tumors recurred in the abdominal walls of 2 patients. Two patients died: one as a result of sepsis, the other because of a rupture of a mycotic aneurysm of the aortic anastomosis. One graft lost to severe rejection was replaced with a second intestinal graft. Eleven to 53 months after transplantation, 7 patients were alive, well, independent of parenteral treatment, and leading apparently normal lifestyles. CONCLUSIONS Transplantation of the intestine alone or as part of a multivisceral transplantation may help rescue otherwise untreatable patients with complicated desmoid tumors.
Collapse
Affiliation(s)
- M A Chatzipetrou
- Department of Surgery, Division of Liver and GI Transplant, University of Miami School of Medicine, FL 33136, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Abstract
Significantly reduced morbidity and mortality is needed before intestinal transplantation will be applicable in most patients with intestinal failure who are on long-term total parenteral nutrition (TPN). However, transplantation does play a role if TPN fails, with failure defined by Medicare as liver failure, frequent line sepsis, major central vein thrombosis, or recurrent dehydration. Of these complications, the relationship between liver failure and subsequent death in high-risk subgroups of long-term TPN patients has been shown clearly. Patients with less than 100 cm of postduodenal small bowel, an end-jejunostomy, no ileocecal valve or cecum, or persistently elevated liver function levels are at high risk for end-stage liver disease (ESLD). Early referral to experienced centers is suggested in these circumstances. High-risk patients may also take part in clinical trials of promising therapies to increase intestinal adaptation and prevent liver failure. Living donors should be considered for transplant candidates to minimize waiting time and optimize HLA matching. ESLD patients need a liver-intestine transplant. Because their waiting-list mortality is very high, their status on the liver waiting list should be elevated if possible. High incidence of early death from sepsis is reported after intestinal transplant, even at experienced centers. Aggressive measures should be taken if uncontrolled sepsis occurs, including discontinuing immunosuppression and removing the graft. Further research is needed in intestinal immunology and in development of strategies to decrease the need for aggressive immunosuppression in these transplant recipients. The ultimate role of intestinal transplantation will be determined by its capacity to show superiority, both in effectiveness and safety, to long-term TPN.
Collapse
Affiliation(s)
- J P Fryer
- Division of Gastroenterology and Hepatology, Inflammatory Bowel Disease Center, Northwestern University Medical School, 676 North St. Clair Street, Suite 880, Chicago, IL 60611, USA.
| |
Collapse
|
28
|
New techniques for prevention and treatment of rejection in intestinal transplantation. Curr Opin Organ Transplant 2000. [DOI: 10.1097/00075200-200009000-00021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
29
|
Stojanovic T, Schlemminger R, Bedke J, Gröne HJ, Heuser M, Leister I, Hecker M, Becker H, Markus PM. In vivo changes in acute rejection of rat small bowel allografts. Transplant Proc 2000; 32:1247-8. [PMID: 10995931 DOI: 10.1016/s0041-1345(00)01208-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
MESH Headings
- Acute Disease
- Animals
- Graft Rejection/pathology
- Graft Rejection/physiopathology
- Hemodynamics
- Intestine, Small/pathology
- Intestine, Small/physiology
- Intestine, Small/transplantation
- Microcirculation/physiopathology
- Rats
- Rats, Inbred BN
- Rats, Inbred Lew
- Transplantation, Heterotopic
- Transplantation, Homologous/immunology
- Transplantation, Homologous/pathology
- Transplantation, Homologous/physiology
- Transplantation, Isogeneic/immunology
- Transplantation, Isogeneic/pathology
- Transplantation, Isogeneic/physiology
Collapse
|
30
|
Kato T, O'Brien CB, Berho M, Nishida S, Levi D, Khan FA, Pinna AD, Nery JR, Ruiz P, Tzakis AG. Improved rejection surveillance in intestinal transplant recipients with frequent use of zoom video endoscopy. Transplant Proc 2000; 32:1200. [PMID: 10995906 DOI: 10.1016/s0041-1345(00)01183-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- T Kato
- Division of Transplantation, University of Miami School of Medicine, Miami, Florida 33101-5809, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
|
32
|
|
33
|
Abstract
Gastrointestinal transplantation is a life-saving option for patients who have chronic intestinal failure and cannot tolerate total parenteral nutrition (TPN). Early referral is important because of the scarcity of donors and the increased risk of complications in debilitated recipients. One-year patient survival rates range from 50% to 70%. Despite the use of intense immune suppression, most patients experience at least 1 episode of graft rejection. More than 80% of the survivors are able to stop TPN and resume an unrestricted oral diet. Patients with functioning grafts have a good quality of life.
Collapse
Affiliation(s)
- N Kumar
- Department of Surgery, University of Western Ontario, London, Ontario, Canada
| | | |
Collapse
|