Isolated intestinal transplantation in adults with nonreconstructible GI tracts

Isolated intestinal transplantation: proof of clinical efficacy

BACKGROUND AND AIMS

Isolated intestinal transplantation has been limited by poor patient and graft survival. If high survival could be achieved and if parenteral nutrition-associated liver disease were reversible, this procedure could be more widely applied, with early liver dysfunction indicating the need for transplant evaluation.

METHODS

Twenty-six patients who had failed parenteral nutrition received 28 isolated intestinal transplants. We analyzed patient and graft survival, the effect of sirolimus on the severity and frequency of rejection, and the reversibility of liver dysfunction after transplant.

RESULTS

Three-year actuarial patient and primary graft survival were 88% and 71%, respectively. Two patients underwent successful retransplants. Twenty-two patients are alive at a mean of 21+/-15 (median 18; range 3-51) months. Actuarial survival with freedom from parenteral support is 81% at 3 years (21 of 26 patients). Actuarial freedom from parenteral support among survivors is 95.5% at 3 years (21 of 22 patients). Early rejection was less frequent with sirolimus (34% vs. 70% without sirolimus) (P=0.007). Moderate and severe rejection was less frequent with sirolimus (1/11 episodes vs. 9/17 episodes without sirolimus) (P=0.05). No grafts were lost after introduction of sirolimus. In all four patients with advanced liver dysfunction, fibrosis and cholestasis regressed within 1 year.

CONCLUSIONS

High patient survival and parenteral nutrition-free survival can be achieved after isolated intestinal transplantation. Sirolimus treatment has eliminated graft loss. Parenteral nutrition-associated liver disease is reversible with intestinal transplantation. Refractory liver dysfunction in patients receiving parenteral nutrition should prompt consideration for isolated intestinal transplantation.

Noncomposite simultaneous liver and intestinal transplantation

Patients with short-gut syndrome may develop total parenteral nutrition-associated liver disease, which may preclude them from isolated intestinal transplantation and require combined liver and intestinal transplantation. Traditionally, these multiorgan transplantations are performed using en bloc liver and intestinal grafts that share portal, hepatic, and mesenteric blood supplies. In the event that severe intestinal rejection occurs, it is prohibitive in these cases to remove the intestinal portion of the graft. Herein we present the case of a patient with short-gut syndrome caused by volvulus and severe cholestatic liver disease who underwent simultaneous intestinal and liver transplantation using separate grafts from the same cadaveric donor. We discuss the technical aspects of the case and the benefit of such an approach.

Endoscopic diagnosis of bleeding Meckel's diverticulum in a multivisceral transplant recipient

Small bowel transplantation has become a life-saving procedure for patients with intestinal failure who fail conventional therapy. Meckel's diverticulum is a rare cause of occult gastrointestinal bleeding that has not been reported in patients receiving intestinal allografts. We report a case in which transplantation of an asymptomatic Meckel's diverticulum as part of a multivisceral allograft led to intestinal bleeding requiring surgical intervention. Endoscopy identified the actual bleeding diverticulum. Diverticulectomy at the time of transplant was not performed due to the difficult operative course, and the need for frequent surveillance ileoscopy, which would be performed across a fresh intestinal anastomosis. The patient underwent resection of the diverticulum, along with 40 cm of ileum, and did not experience further bleeding.

An integrated approach to intestinal failure: results of a new program with total parenteral nutrition, bowel rehabilitation, and transplantation

Intestinal failure can be treated with bowel rehabilitation, total parenteral nutrition, or intestinal transplantation. Little has been done to integrate these therapies for patients with intestinal insufficiency or failure and to develop an algorithm for appropriate use and timing. We established a multidisciplinary program using bowel rehabilitation, total parenteral nutrition, or intestinal transplantation as appropriate in a large population. Evaluation included clinical, pathologic, and psychosocial assessments and assignment to therapy based on the results of this evaluation. Of 59 patients evaluated for life-threatening complications of intestinal failure, 68% were considered appropriate candidates for transplantation, 10% were managed with rehabilitation, and 17% were maintained on optimized long-term parenteral nutrition. Nineteen transplants were performed, with 78% patient survival and 66% graft survival. Patient survival among isolated intestine recipients was 90%. All patients managed with rehabilitation were weaned from parenteral nutrition within 6 months. Long-term management with parenteral nutrition resulted in a significant number of deaths both among patients waiting for a transplant and those who were poor candidates for transplant. Intestinal rehabilitation, when successful, is optimal. For patients with irreversible intestinal failure, isolated intestinal transplantation holds particular promise. Parenteral nutrition is plagued by high failure rates among this population of debilitated patients compared with the general parenteral nutrition population. Integration of these therapies, with individualization of care based on a multidisciplinary approach and perhaps with earlier isolated intestinal transplantation for patients with irreversible intestinal failure, should optimize survival.

Intestinal transplantation before and after the introduction of sirolimus

INTRODUCTION

Small bowel transplantation has been limited by high rates of rejection and graft loss. In June 2000, we began using sirolimus, an immunosuppression agent with proven efficacy in kidney transplantation. We reviewed results among intestinal transplant recipients before and after the introduction of sirolimus.

METHODS

Thirty-one intestinal transplants were performed in 29 patients at our center between July 1998 and April 2001. All patients were followed for at least 30 days posttransplant. In the first 19 transplants (group 1), patients received tacrolimus, steroids, and antibody induction therapy (either daclizumab or OKT3). In the next 12 consecutive transplants (group 2), patients received tacrolimus, steroids, basiliximab, and sirolimus.

RESULTS

Eighteen children (7 males and 11 females, mean age 2.1+/-2.2 years) and 11 adults (9 males and 2 females, mean age 38.1+/-12.4 years) underwent transplantation. All patients survived transplantation. The overall reoperation rate was 1.7 procedures per patient in group 1 and 1.1 procedures per patient in group 2. The most common indications were abscess (n=7), planned second look (n=7), leaks/fistulas (n=6), dehiscence (n=6), obstruction (n=4), ischemic bowel (n=3), perforations (n=3), stomal complications (n=3), and graft removal (n=3). The incidence of biopsy-proven rejection in the first 30 days was 73.7% in group 1 and 16.7% in group 2 (P<0.002). Sirolimus was temporarily held or discontinued in 66.7% of patients. Actuarial 1-year graft survival was 91.7% with sirolimus and 57.9% without sirolimus (P<0.04). Actuarial 1-year patient survival was 91.7% with sirolimus and 79% without sirolimus (P=0.12).

CONCLUSIONS

An immunosuppressive regimen that includes sirolimus has improved graft survival. Furthermore, this regimen has significantly decreased the incidence of early rejection and has eliminated early graft loss caused by fulminant rejection.