Intestinal transplantation

Intestinal transplantation: current improvements and perspectives

PURPOSE OF REVIEW

This review summarizes the most recent relevant knowledge in clinical practice in the field of intestinal transplantation.

RECENT FINDINGS

Three important factors that have allowed improving results during the last few years are reviewed here. The first relates to the development of a different approach to tackle the underlying cause of intestinal failure and to the patient's characteristics in terms of liver function, age, and body size. The second involves immune modulation and especially the immunosuppressive regimen at induction. The third refers to posttransplantation monitoring, in particular the diagnosis and treatment of intestinal graft rejection and lymphoproliferative disorders. Patient status and referral for intestinal transplantation remain debated. The Intestinal Transplant Registry and a report from an individual program have demonstrated the relationship between a patient's pretransplant status and outcome. Candidacy for intestinal transplantation was analysed in a European survey of home parenteral nutrition patients. Early referral and listing are important for successful outcomes after intestinal grafting.

SUMMARY

Patient management should include therapies adapted to each stage of intestinal failure based on a multidisciplinary approach in centers involving surgery, gastroenterology, parenteral nutrition expertise, home parenteral nutrition programs, and liver-intestinal transplantation experience. Timing for referral of patients in specialized centers remains a crucial issue.

Antenatal diagnosis of bowel dilatation in gastroschisis is predictive of poor postnatal outcome

PURPOSE

Although gastroschisis infants usually have a good outcome, there remains a cohort of babies who fare poorly. We inquired whether the presence of bowel dilatation in utero is predictive of postnatal course in infants with gastroschisis.

METHODS

We compared the clinical course of infants who had bowel dilatation with those who did not. Bowel dilatation was defined as more than 20 mm in cross-sectional diameter on ultrasound at any gestational age. Outcome measures used were length of time of parenteral nutrition, death, and surgery for intestinal failure.

RESULTS

A review of 170 infants with gastroschisis identified 74 who had dilatation of more than 20 mm (43.5%). There was no significant difference in the incidence of intestinal atresia in those with bowel dilatation and those without (P = .07). Those with bowel dilatation spent a longer period on parenteral nutrition. There were significantly more deaths in the group with bowel dilatation (P = .01). There was no significant difference in the number of infants requiring surgery for intestinal failure between the 2 groups (P = .47).

CONCLUSIONS

We found that sonographically detected bowel dilatation more than 20 mm in utero in fetuses with gastroschisis may have value in predicting clinically significant adverse postnatal outcomes.

Surgical complications after intestinal transplantation in infants and children--UK experience

Surgical complications have a significant impact on morbidity and mortality following intestinal transplantation (ITx). Birmingham Children's Hospital commenced intestinal transplantation in 1993 and the following surgical strategies evolved: (a) pretransplant abdominal tissue expanders, 1998; (b) combined en-bloc reduced liver and intestinal transplantation (CRLITx), 1998; (c) staged abdominal closure, 2001; (d) preservation of graft duodenal artery, 2005.

AIM

An internal audit was performed to document the surgical complications after ITx and to evaluate strategies in the management and prevention of complications.

METHODS

A retrospective analysis of the medical records from January 1993 to June 2007 was conducted to identify surgical complications, evaluate management strategies, and report outcome following ITx.

RESULTS

Forty-six children underwent 49 ITx (9 isolated intestinal, 39 combined liver and intestinal [CLITx], and 1 multivisceral transplant). Twenty three children had CRLITx since 1998, although there were none before 1997. The median donor: recipient weight ratio in CLITx was 2.2:1 (range, 0.67:1-6.70:1). Twenty-six children experienced 29 (59%) surgical complications: portacaval shunt thrombosis (n = 2, none alive); graft duodenal stump leakage (n = 3, 2 alive); spontaneous bowel perforation(n = 6, 2 alive); sub-acute bowel obstruction (n = 6, all alive); abdominal compartment syndrome ([ACS], n = 4, 2 alive); pancreatic leak (n = 3, 2 alive); biliary complications (n = 22, 17 alive ) failed staged abdominal closure with wound sepsis requiring skin grafting into the bowel (n = 1, alive), wound dehiscence (n = 1, alive), anastomotic leak (n = 1, alive) and intra-abdominal bleeding (n = 1,alive), primary nonfunction (n = 1, 1 died). Following the complications of ACS in children with primary abdominal closure and graft duodenal stump leaks in 2004, we modified our strategies in 2005 to include staged abdominal closure with recipient to donor weight mismatch, and preservation of the gastroduodenal artery during donor organ procurement in addition to pre transplant abdominal tissue expansion. Fifteen children with recipient and donor weight mismatch subsequently required staged closure of the abdomen and none of them developed ACS. Twelve children had gastroduodenal artery preserved and none developed graft duodenal stump leaks. Twenty-four of the 46 (52%) are alive 6 months to 10 years post transplant.

CONCLUSION

Evolving strategies may avoid or reduce surgical complications commonly seen after intestinal transplantation and thus contribute to an improved outcome.

Gastrointestinal motility disorders in adolescent patients: transitioning to adult care

A wide spectrum of gastrointestinal motility disorders present in childhood. Some are unique to children, especially congenital disorders including certain pseudo-obstruction disorders or those associated with anatomic developmental defects, whereas others are common adult disorders, such as achalasia, that rarely manifest in children. This article reviews the pediatric presentations and sequelae of childhood gastrointestinal motility disorders and then discusses long-term management issues for these children as they progress into adulthood. The goal is to optimize medical care and ensure the adequate nutritional status essential for neurocognitive and psychosocial development of the child. Multidisciplinary care from specialists, including gastroenterologists, psychologists, and pain specialists, is often required to optimize the lives of these patients.