Intestinal transplantation: 1997 report of the international registry. Intestinal Transplant Registry

Skipped Aganglionic Lengthening Transposition (SALT) is highly effective to achieve enteral autonomy in selected patients with intestinal failure secondary to total intestinal aganglionosis

BACKGROUND

Intestinal Failure, parenteral nutrition (PN) dependence, and subsequent liver disease are the most challenging and life-threatening complications of short bowel syndrome experienced by patients with total intestinal aganglionosis. Skipped Aganglionic Lengthening Transposition (SALT) showed to be a promising procedure to overcome such problems. We herein report the results of two patients who underwent SALT at the Umberto Bosio Center for Digestive Diseases.

PATIENTS AND METHODS

Between November 2019 and July 2022, 2 patients with total intestinal aganglionosis underwent SALT as autologous intestinal lengthening procedure. Perioperative data and long-term outcomes are reported. Patient #1-A 18 month-old male (PN dependant) with 30 cm of ganglionated bowel at birth experienced a 35% increase of intestinal length after SALT (from 43 to 58 cm) thanks to three 5 cm interposed aganglionic loops. Postoperative course was uneventful and he was totally weaned by PN after 28 months postoperatively. He is without PN only receiving enteric feeding 53 months after the procedure. Patient #2-A 11 year-old female (PN dependant) with 100 cm of ganglionated jejunum underwent SALT at 11 years and experienced a 19% increase of bowel length thanks to four 5 to 7 cm interposed aganglionic loops. Postoperatively she required excision of two out of the four loops due to severe strictures and inadequate perfusion with a subsequent overall 10% increase of length after SALT. Of note, she improved significantly with a progressive reduction of PN that has been stopped after 18 months.

CONCLUSION

Skipped aganglionic lengthening transposition (SALT) seems to be very effective in improving nutrients absorption in patients with total intestinal aganglionosis by increasing absorptive bowel surface and decelerating intestinal flow for a longer and more effective contact of enteric material with ileal mucosa. Provided these impressive results are confirmed in the very long-term, SALT could become a valid alternative for the treatment of patients with total intestinal aganglionosis carrying at birth at least 20 to 30 cm of ganglionated jejunum.

Results of an International Survey on Feeding Management in Infants With Short Bowel Syndrome-Associated Intestinal Failure

OBJECTIVES

Short bowel syndrome (SBS) is a complex and rare condition (incidence 1200/100,000 live births) that requires a multidisciplinary team approach to management. In January 2019, the first European Reference Network on Rare and Inherited Congenital Anomalies (ERNICA) Intestinal Failure (IF) workshop was held. Several questions about the strategies used in managing IF associated with SBS were devised. The aim of our study was to collect data on the enteral feeding strategies adopted by the ERNICA centres.

METHODS

A questionnaire (36 questions) about strategies used to introduce enteral nutrition post-operatively and start complementary food/solids in infants with SBS associated IF was developed and sent to 24 centres in 15 countries that participated in the ERNICA-IF workshop. The answers were collated and compared with the literature.

RESULTS

There was a 100% response rate. In infants, enteral nutrition was introduced as soon as possible, ideally within 24-48 hours post-small intestinal surgical resection. In 10 of 24 centres, bolus feeding was used, in nine continuous, and in five a combination of both. Twenty-three centres used mothers' own milk as the first choice of feed with extensively hydrolysed feed, amino acid-based feed, donor human milk or standard preterm/term formula as the second choice. Although 22 centres introduced complementary/solid food by 6 months of age, food choice varied greatly between centres and appeared to be culturally based.

CONCLUSIONS

There is diversity in post-surgical enteral feeding strategies among centres in Europe. Further multi-centre studies could help to increase evidence-based medicine and management on this topic.

Indications of Intestinal Transplantation

"The intestinal transplantation is reserved for patients with life-threatening complications of permanent intestinal failure or underlying gastrointestinal disease. The choice of the allograft for a particular patient depends on several factors and the presence of concurrent organ failure, and availability of the donor organs, and specialized care. Combined liver and intestinal transplant allows for patients who have parenteral nutrition-associated liver disease a possibility of improved quality of life and nutrition as well as survival. Intestinal transplantation has made giant strides over the past few decades to the present era where current graft survivals are comparable with other solid organ transplants."

Parenteral Nutrition-Associated Cholestasis Related to Parental Care

Parenteral nutrition-associated cholestasis (PNAC) is a complication not uncommon in the pediatric population. In severe cases, patients require a liver transplant. To our knowledge, we report the only case of PNAC with end-stage liver failure in a child with short bowel syndrome that resolved with a change in caretaker. Until his care was transferred from his abusive parents, he was frequently admitted for infection and sepsis. His liver function vastly improved from aspartate aminotransferase (AST) 3139 units/L, conjugated bilirubin 25.9 mg/dL to AST 47 units/L, direct bilirubin 0.3 mg/dL under the care of his attentive foster mother, and a liver transplant was no longer necessary. Bacterial infection and sepsis are risk factors correlated with patients with PNAC requiring liver transplant. Prevention of infection by a good caregiver may be a means to reduce the incidence of PNAC.

Nutrition Management of Small Bowel Transplant Patients

Nutrition therapy after small bowel or combined liver/small bowel transplantation is challenging. The objective is to restore enteral autonomy to a patient with a complex past surgical history and equally complex posttransplant immunosuppressive regimen in the context of a newly created surgical anatomy. Improved surgical techniques and immunosuppressive regimens have led to superior outcomes. Accompanying these advances is a range of nutrition issues that require specific management strategies. This review outlines the current clinical practice and decision making used to create individualized nutrition regimens for small bowel or combined liver/small bowel transplant recipients. Successful small bowel transplant outcomes require a coordinated effort from a transplant team to restore nutritional autonomy to transplant recipients and free them from parenteral nutrition.

Quality of Life after Intestinal Transplantation

As technology introduces more advanced therapies, individuals have realized that quantity or length of life may not always be the ultimate goal in treating disease. The quality of life at times is as important as length of life. In this article, we review the literature regarding quality of life after intestinal transplantation. Published data on patient survival are briefly reviewed and the available studies investigating quality of life are examined. Few studies have been performed to date, but the limitations and implications of the available studies are summarized.

Is There a Role for Living Donor Intestine Transplants?

The use of living donors with intestinal transplantation is controversial because it may not significantly improve candidate access to organs when intestine-only grafts are needed, and may involve excessive donor risk when combined liver-intestine grafts are required. Although limited data are available for comparison at this time, graft and patient survival rates for intestinal transplantations using living donors are no different than for deceased donor transplantations. Potential benefits that may be provided to the intestine transplant recipient through the use of living donors include better HLA matching, shorter ischemia times, better bowel preparation, and better opportunities for introducing immunomodulatory strategies. Conversely, living intestine donors are at risk for mortality, significant morbidity, financial loss, and psychologic trauma. The long-term outcomes of living intestine donors have not yet been reported. Ultimately, these data are essential before the wider use of living donors can be advocated for intestinal transplantation.

Difficulties, guidelines and review of developing an acute rejection model after rat intestinal transplantation

Experimental small bowel transplantation (SBT) in rats has been proven to be a useful tool for the study of ischemia-reperfusion and immunological aspects related to solid organ transplantation. However, the model is not completely refined, specialized literature is scarce and complex technical details are typically omitted or confusing. Most studies related to acute rejection (AR) use the orthotopic standard, with small sample sizes due to its high mortality, whereas those studying chronic rejection (CR) use the heterotopic standard, which allows longer term survival but does not exactly reflect the human clinical scenario. Various animal strains have been used, and the type of rejection and the timing of its analysis differ among authors. The double purpose of this study was to develop an improved unusual AR model of SBT using the heterotopic technique, and to elaborate a guide useful to implement experimental models for studying AR. We analyzed the model's technical details and expected difficulties in overcoming the learning curve for such a complex microsurgical model, identifying the potential problem areas and providing a step-by-step protocol and reference guide for future surgeons interested in the topic. We also discuss the historic and more recent options in the literature.

Definitions of intestinal failure and the short bowel syndrome

The European Society for Clinical Nutrition and Metabolism defined intestinal failure (IF) as "the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth". IF is classified as type 1-acute, type 2-prolonged acute and type 3-chronic IF. A short bowel syndrome (SBS) due to the intestinal malabsorption associated with a functional small intestine length of less than 200 cm is the most frequent mechanism of IF. SBS is a difficult and multifaced disease. Complications due to SBS itself and to treatments, such as long term home parenteral nutrition, can adversely affect the patient outcome. The care of SBS requires complex technologies and multidisciplinary and multiprofessional activity and expertise. Patient outcome is strongly dependent on care and support from an expert specialist team. This paper focuses on the aspects of the pathophysiology and on the complications of SBS, which are most relevant in the clinical practice, such as intestinal failure associated liver disease, renal failure, biliary and renal stones, dehydration and electrolyte depletion, magnesium deficiency and D-lactic acidosis.

Intestinal transplantation

Intestinal transplantation has now emerged as a lifesaving therapeutic option and standard of care for patients with irreversible intestinal failure. Improvement in survival over the years has justified expansion of the indications for intestinal transplantation beyond the original indications approved by Center for Medicare and Medicaid services. Management of patients with intestinal failure is complex and requires a multidisciplinary approach to accurately select candidates who would benefit from rehabilitation versus transplantation. Significant strides have been made in patient and graft survival with several advancements in the perioperative management through timely referral, improved patient selection, refinement in the surgical techniques and better understanding of the immunopathology of intestinal transplantation. The therapeutic efficacy of the procedure is well evident from continuous improvements in functional status, quality of life and cost-effectiveness of the procedure. This current review summarizes various aspects including current practices and evidence based recommendations of intestinal transplantation.

Risks and Epidemiology of Infections After Intestinal Transplantation

Intestinal transplantation has become a well-accepted and successful procedure to save the lives of patients suffering from intestinal failure and who have developed life-threatening complications of parenteral nutrition. Advances in all aspects of care, from the role of multidisciplinary intestinal rehabilitation services prior to transplant to the development strategies for early recognition of infectious sequelae and even the increasing availability of preventive strategies, have led to improved outcomes and a dramatic decline in infection-associated morbidity and mortality in children undergoing intestinal transplantation. Improvements in surgical techniques and immunosuppressive regimens have been essential components in these improvements, reducing risk of infection through reduction of technical complications and more optimal immunosuppression regimens. In addition, the development of molecular tools for early recognition of viral pathogens and an understanding of the timing and risks for infection have allowed for earlier and more successful treatments. Despite these improvements, infectious sequelae remain an important problem in this population, and additional efforts are needed to further minimize the risk of infectious sequelae in those children requiring this procedure.

More on 'No Gut Syndrome': A case report

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Highlights the entity ‘No Gut Syndrome’ which arises as a consequence of massive small bowel resection.

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This situation is faced more often than reported in literature. We earlier reported 2 similar cases as well as a literature review.

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Life-long PN associated complications and outcomes in these patients pose a clinical dilemma.

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This report continues to assert the need to proceed with a NTE, and the successful outcomes of many patients thereafter.

Introduction

No Gut Syndrome refers to a condition which results after a near total enterectomy (NTE) has been performed. These patients are unable to sustain life without life-long parenteral nutrition (PN). Re-establishment of bowel continuity, complications, quality of life (QoL), and overall outcomes are important aspects to be considered in patients who might need a NTE. We have previously reported two similar cases as well as a literature review in patients with No Gut Syndrome. In the present report, we present an additional case and an update of the literature.

Presentation of the case

A 62-year old man with multiple co-morbidities presented with features of acute small bowel obstruction. Exploratory laparotomy revealed severe mesenteric ischemia and extensive small bowel necrosis. Patient eventually underwent a NTE and was discharged on parenteral nutrition.

Discussion

Near total enterectomy (NTE) is a clinical condition in which a patient is left without or with minimal length of small bowel along with either gastrointestinal continuity or exteriorization of the proximal end. This condition has remained a dilemma for surgeons worldwide chiefly as a result of its perceived incompatibility with life. There are only a few available options for proceeding with treatment, however maintenance on long term parenteral nutrition has shown promising results.

Conclusion

Long term parenteral nutrition serves as a viable treatment option for managing patients after a NTE.

Imaging findings in children with proliferative disorders following multivisceral transplantation

BACKGROUND

Multivisceral transplantation represents an important treatment option for children with intestinal failure. The attendant immunosuppression can lead to a spectrum of cellular proliferations including benign and malignant smooth muscle tumors and lymphoproliferative disorders, many related to cellular dysregulation from Epstein-Barr virus infection.

OBJECTIVE

The purpose of this study is to investigate the rates of post-transplantation proliferative disorders among children with multivisceral transplantation and to characterize the imaging and pathological features of these disorders.

MATERIALS AND METHODS

We identified all consecutive children who underwent multivisceral transplant from August 2004 to October 2011 with at least 27 months of clinical and imaging follow-up. We reviewed medical records to determine the underlying causes of the multivisceral transplant, age at transplantation, onset of neoplasm development, and outcome. Two pediatric radiologists reviewed all imaging studies independently and diagnosis of disease was made by consensus interpretation. Pathological specimens were reviewed for histopathological findings of post-transplantation neoplasm in this pediatric patient population.

RESULTS

The study population consisted of 14 consecutive pediatric patients (7 boys and 7 girls; mean age 26 months, range 4-113 months). Of these 14 children, 4 (29%) developed histologically confirmed post-transplant neoplasms at a mean time of 2.4 years after multivisceral transplantation. Types of neoplasms included post-transplant lymphoproliferative disorder (PTLD) in three (21%) and Epstein-Barr-virus-associated smooth muscle tumor in two (14%). (One child developed both neoplasms following transplantation). Both children with smooth muscle tumor associated with Epstein-Barr virus presented with characteristic hypointense solid masses with peripheral rim enhancement on cross-sectional imaging studies. The mortality rate of children who developed post-transplant neoplasms was higher than that of those who did not develop post-transplant neoplasm (50% vs. 10%, P = 0.17), suggesting a possible risk factor for death.

CONCLUSION

Post-transplant neoplasm in children with multivisceral transplantation occurs with high frequency, often presents as Epstein-Barr-virus-associated smooth muscle tumor showing characteristic peripheral rim enhancement on cross-sectional imaging studies.

The concept of gut rehabilitation and the future of visceral transplantation

In the 1990s, the introduction of visceral transplantation fuelled interest in other innovative therapeutic modalities for gut rehabilitation. Ethanol lock and omega-3 lipid formulations were introduced to reduce the risks associated with total parenteral nutrition (TPN). Autologous surgical reconstruction and bowel lengthening have been increasingly utilized for patients with complex abdominal pathology and short-bowel syndrome. Glucagon-like peptide 2 analogue, along with growth hormone, are available to enhance gut adaptation and achieve nutritional autonomy. Intestinal transplantation continues to be limited to a rescue therapy for patients with TPN failure. Nonetheless, survival outcomes have substantially improved with advances in surgical techniques, immunosuppressive strategies and postoperative management. Furthermore, both nutritional autonomy and quality of life can be restored for more than two decades in most survivors, with social support and inclusion of the liver being favourable predictors of long-term outcome. One of the current challenges is the discovery of biomarkers to diagnose early rejection and further improve liver-free allograft survival. Currently, chronic rejection with persistence of preformed and development of de novo donor-specific antibodies is a major barrier to long-term graft function; this issue might be overcome with innovative immunological and tolerogenic strategies. This Review discusses advances in the field of gut rehabilitation, including intestinal transplantation, and highlights future challenges. With the growing interest in individualized medicine and the value of health care, a novel management algorithm is proposed to optimize patient care through an integrated multidisciplinary team approach.

Intestinal transplant registry report: global activity and trends

The Registry has gathered information on intestine transplantation (IT) since 1985. During this time, individual centers have reported progress but small case volumes potentially limit the generalizability of this information. The present study was undertaken to examine recent global IT activity. Activity was assessed with descriptive statistics, Kaplan-Meier survival curves and a multiple variable analysis. Eighty-two programs reported 2887 transplants in 2699 patients. Regional practices and outcomes are now similar worldwide. Current actuarial patient survival rates are 76%, 56% and 43% at 1, 5 and 10 years, respectively. Rates of graft loss beyond 1 year have not improved. Grafts that included a colon segment had better function. Waiting at home for IT, the use of induction immune-suppression therapy, inclusion of a liver component and maintenance therapy with rapamycin were associated with better graft survival. Outcomes of IT have modestly improved over the past decade. Case volumes have recently declined. Identifying the root reasons for late graft loss is difficult due to the low case volumes at most centers. The high participation rate in the Registry provides unique opportunities to study these issues.

Health-related quality of life in pediatric intestinal transplantation

To determine HRQOL after pediatric intestinal transplantation. Thirty-four IT survivors from 1999 to 2012 were asked to complete age-specific HRQOL non-disease-specific questionnaires: TAPQOL (0-4 yr), KINDL-R (5-7 yr; 8-12 yr; 13-17 yr), and SF-36v2 (>18 yr), all validated with Spanish population. Primary caregiver completed a SF-36 questionnaire and CBI. Thirty-one participants were included. Median age was 10.2 yr (1-29) and time after transplant 4.4 yr (0-13). Overall patient scores were 78.2 ± 10.6 (n = 8), 83.3 ± 9.7 (n = 6), 72.2 ± 9.21 (n = 6), 80.5 ± 12.4 (n = 7), and 82.2 ± 12.4 (n = 4) for each age group. Highest scores were obtained for vitality (group I), self-esteem (group IV), and physical and social functioning and emotions (group V). Lowest scores were obtained in appetite and behavior (I), family and school (III), and chronic disease perception (III, IV). No significant differences were found between caregivers and their children. CBI showed stress in 52%. SF-36 for caregivers was lower than general population. No significant differences were found depending on relevant clinical and sociodemographic data. HRQOL was acceptable and improved with age and time since transplantation. Parents had a slighter own QOL and worse perception of health than their children. When successful, intestinal transplantation allows a normal life in most patients and can be offered as an attractive option.

India's first successful intestinal transplant: the road traveled and the lessons learnt

Intestinal transplant is a therapeutic challenge not just surgically but also logistically because of the multidisciplinary expertise and resources required. A large proportion of patients who undergo massive bowel resection and develop intestinal failure have poor outcome, because of inability to sustain long-term parenteral nutrition and limited availability of intestinal and multi-visceral transplantation facilities. We report the first successful isolated intestinal transplant from India.

Role of probiotics in short bowel syndrome in infants and children--a systematic review

Short bowel syndrome (SBS) is a cause of significant morbidity and mortality in children. Probiotics, due to their beneficial effects on the gastrointestinal tract (e.g., improving gut barrier function, motility, facilitation of intestinal adaptation and decreasing pathogen load and inflammation) may have a therapeutic role in the management of SBS. To conduct a systematic review of the current evidence for the effects of probiotic supplementation in children with SBS, the standard Cochrane methodology for systematic reviews was used. The databases, Pubmed, Embase, ACTR, CENTRAL, and the international trial registry, and reference lists of articles were searched for randomised (RCT) or quasi-randomised controlled trials reporting on the use of probiotics in SBS. Our search revealed no RCTs on the use of probiotics in children with SBS. We found one small cross-over RCT (placebo controlled crossover clinical trial), one case control study and nine case reports on the use of probiotics in children with SBS. In the crossover RCT, there was no consistent effect on intestinal permeability (primary outcome) after supplementation with Lactobacillus rhamnosus (LGG) in nine children with SBS. The case control study (four cases: four controls) reported a trend for increase in height and weight velocity and improvement in non-clinical outcomes, such as gut flora, lymphocyte count and serum prealbumin. Five of the nine case reports showed that children (n = 12) with SBS were benefited (e.g., cessation of diarrhoea, improved faecal flora, weight gain and weaning from parenteral nutrition) by probiotic supplementation. The remaining four reported on the adverse effects, such as Lactobacillus sepsis (n = 3) and D-lactic acidosis (n = 2). There is insufficient evidence on the effects of probiotics in children with SBS. The safety and efficacy of probiotic supplementation in this high-risk cohort needs to be evaluated in large definitive trials.

Post-transplant lymphoproliferative disorders in liver transplant recipients: a clinicopathological study

BACKGROUND AND AIMS

Complications after liver transplantation are major factors that determine the prognosis of patients. In this study, we aimed at investigating an important though less frequently occurring complication, post-transplant lymphoproliferative disorders (PTLD), in a single institution after liver transplantation.

METHODS

15 cases with a diagnosis of PTLD in post-liver transplant patients were retrieved from our archive and the clinicopathological features reviewed.

RESULTS

The overall incidence of PTLD was 2.3% (n=15/658), and the incidence was much higher in the paediatric than the adult age groups, being 11.1% (9/81) and 1% (6/577), respectively. The median time of presentation was 16 months after transplantation (occurrence time ranging from 2 to 87 months after transplantation). Lymph nodes, gastrointestinal tract and graft liver were the commonest sites of involvement. 11 cases were classified as monomorphic PTLD according to WHO classification and the majority (n=10/11) of them were of B cell differentiation. 12 of the total 15 PTLD cases showed a positive result for Epstein-Barr virus-encoded RNAs with in situ hybridisation. Eight patients were alive at the time of review, and two of them suffered from recurrence of the PTLD. Among the seven patients who died, six succumbed within 1 year from the diagnosis of PTLD.

CONCLUSIONS

Despite its relative rarity as a complication for liver transplantation, PTLD imposes significant effects on the morbidity, mortality and treatment implications in postliver transplant patients. The clinicopathological data would hopefully provide better insight into the surveillance and management for susceptible patients.

Role of high mobility group box chromosomal protein 1 in ischemia-reperfusion injury in the rat small intestine

BACKGROUND

High mobility group box chromosomal protein 1 (HMGB1) has recently been shown to be an important late mediator of endotoxic shock and sepsis. The purpose of the present study was to investigate the role of HMGB1 in response to ischemia-reperfusion injury.

METHODS

Ischemia-reperfusion injury was induced in male Wistar rats by clamping the superior mesenteric artery for 60 min. Using this model, the serum concentrations and localization of HMGB1 were investigated. The histologic findings from reperfused intestines and the survival rates were compared between the anti-HMGB1 antibody treatment groups (group A treated with 6.0 mg/kg antibody and group B with 0.6 mg/kg antibody) and the control antibody treatment group (control group).

RESULTS

Serum HMGB1 concentrations increased early after reperfusion and peaked at 3 h. Immunohistochemistry for HMGB1 revealed a high degree of positive staining in the epithelial cells of the damaged villi. Anti-HMGB1 antibody treatment significantly reduced this damage (P < 0.05) and improved the 48-h survival rate (90% in group A versus 50% in the controls; P < 0.05).

CONCLUSIONS

These results suggest that HMGB1 plays a key role in small intestinal ischemia-reperfusion injury.

An overview of intestine and multivisceral transplantation

Intestine transplantation remains a formidable clinical and immunologic challenge. With newer immunosuppressive agents and accumulated experience, the survival outcomes for these patients are improving. The relationship of recipient preexisting conditions with the risk of postoperative events clearly emphasize the necessity of early referral of patients with intestinal failure to expert transplant program before the onset of life-threatening complications.30 With increased awareness and knowledge regarding referral criteria, transplant criteria, optimal time for transplantation, and medication regiments, improved patient outcomes after intestine and multivisceral transplant will be achieved.

Pretransplant predictors of survival after intestinal transplantation: analysis of a single-center experience of more than 100 transplants

INTRODUCTION

Outcomes after intestinal transplantation (ITx) have steadily improved. There are few studies that assess factors associated with these enhanced results. The purpose of this study was to examine peri-ITx variables and survival.

METHODS

A review of a prospectively maintained database was undertaken and included all patients undergoing ITx from 1991 to 2010. The study endpoints were patient and graft survival. Data collection included 44 variables. Survival was computed using Kaplan-Meier methods. Univariate analysis was conducted (log-rank test) with significance set at P less than or equal to 0.20. Multivariate analysis of significant variables was conducted using model reduction by backward elimination variable selection method with significance set at P less than 0.05.

RESULTS

Eighty-eight patients received 106 ITx. The majority of recipients were male, Latino, and children. The leading causes of intestinal and liver failure were gastroschisis and parenteral nutrition. Grafts transplanted were isolated intestine (24%), liver-intestine (62%), and multivisceral (14%). Overall 1- and 5-year patient and graft survival were 80% and 65%, and 74% and 64%, respectively. Significant univariate survival predictors were weight less than 20 kg, children, liver-inclusive allograft, panel reactive antibody less than 20%, absence of donor-specific antibody, negative crossmatch, warm ischemia time less than 60 min, absence of recipient splenectomy, interleukin-2 receptor antagonist induction, and era. Significant multivariate survival predictors were absence of donor-specific antibody, absence of recipient splenectomy, and liver-inclusive graft type.

CONCLUSION

This large, single-center ITx experience confirms a marked improvement in outcome over time. Several important factors were associated with survival, and these factors can potentially be adjusted before ITx. These findings should refocus future efforts on strategies to improve treatment and prevent graft loss.

Short bowel syndrome

The short bowel syndrome (SBS) is a state of malabsorption following intestinal resection where there is less than 200 cm of intestinal length. The management of short bowel syndrome can be challenging and is best managed by a specialised multidisciplinary team. A good understanding of the pathophysiological consequences of resection of different portions of the small intestine is necessary to anticipate and prevent, where possible, consequences of SBS. Nutrient absorption and fluid and electrolyte management in the initial stages are critical to stabilisation of the patient and to facilitate the process of adaptation. Pharmacological adjuncts to promote adaptation are in the early stages of development. Primary restoration of bowel continuity, if possible, is the principle mode of surgical treatment. Surgical procedures to increase the surface area of the small intestine or improve its function may be of benefit in experienced hands, particularly in the paediatric population. Intestinal transplant is indicated at present for patients who have failed to tolerate long-term parenteral nutrition but with increasing experience, there may be a potentially expanded role for its use in the future.

Monitoring cytomegalovirus T-cell immunity in small bowel/multivisceral transplant recipients

BACKGROUND

Cytomegalovirus (CMV) is a major cause of graft failure and posttransplantation mortality in intestinal/multivisceral transplantation. CMV infection exhibits a wide range of clinical manifestations from asymptomatic infection to severe CMV disease. STUDY'S PURPOSE: The purposes of this study were to assess the utility of measuring CMV-specific cellular immunity in bowel/multivisceral transplant recipients and to provide additional information on the risk of infection and development of CMV disease.

METHODS

We studied 10 bowel/multivisceral transplant recipients to investigate the kinetics of CMV infection using real-time polymerase chain reaction (on blood and biopsy tissue samples) and CMV-specific T-cell reconstitution by Enzyme-linked ImmunoSPOT Assay (ELISPOT) that enumerates Interferon-gamma-secreting CMV-specific T cells upon in vitro stimulation with viral antigens (pp65 and IE-1).

RESULTS

All patients were seropositive for CMV. According to the pattern of T-cell reconstitution occurring either within the first month after transplantation or later, patients were classified as early (n = 7) or late responders (n = 3). Clinically, early responder patients (3/7; 43%) experienced asymptomatic or mild CMV infections, whereas all late responders (3/3; 100%) developed moderate or severe CMV disease. A reduction in mean and peak CMV viral load was observed in early responders, whereas the onset time of infection did not differ significantly between early and late CMV responders.

CONCLUSIONS

A good and early reconstitution of CMV-specific T-cell immune responses after transplantation is a critical determinant in controlling CMV infections. Simultaneous monitoring of CMV infection and CMV-specific T-cell immunity predicts T-cell-mediated control of CMV infection.

Outcomes in children after intestinal transplant

OBJECTIVE

The survival rates after pediatric intestinal transplant according to underlying disease are unknown. The objective of our study was to describe the population of pediatric patients receiving an intestinal transplant and to evaluate survival according to specific disease condition.

PATIENTS

Pediatric patients (< or =21 years of age) with intestinal failure meeting criteria for intestinal transplant were included in the study.

METHODS

A retrospective review of the United Network for Organ Sharing intestinal transplant database (January 1, 1991, to May 16, 2008), including all pediatric transplant centers participating in the United Network for Organ Sharing, was conducted. The main outcome measures were survival and mortality.

RESULTS

Eight hundred fifty-two children received an intestinal transplant (54% male). Median age and weight at the time of transplant were 1 year (interquartile rage: 1-5) and 10.7 kg (interquartile rage: 7.8-21.7). Sixty-nine percent of patients also received a simultaneous liver transplant. The most common diagnoses among patients who received a transplant were gastroschisis (24%), necrotizing enterocolitis (15%), volvulus (14%), other causes of short-gut syndrome (19%), functional bowel syndrome (16%), and Hirschsprung disease (7%). The Kaplan-Meier curves demonstrated variation in patient survival according to diagnosis. Cox regression analysis confirmed a survival difference according to diagnosis (P < .001) and demonstrated a survival advantage for those patients listed with a diagnosis of volvulus (P < .01) compared with the reference gastroschisis. After adjusting for gender, recipient weight, and concomitant liver transplant, children with volvulus had a lower hazard ratio for survival and a lower risk of mortality.

CONCLUSIONS

Survival after intestinal transplant was associated with the underlying disease state. The explanation for these findings requires additional investigation into the differences in characteristics of the population of children with intestinal failure.

Short bowel syndrome: epidemiology and etiology

Pediatric short bowel syndrome (SBS) is most commonly caused by congenital or acquired conditions of the newborn. SBS is associated with an inability of the bowel to adequately absorb water and nutrients in sufficient quantities to meet caloric, fluid, and electrolyte demands, thus necessitating dependence on parenteral nutrition (PN). It is this dependence on PN, that is responsible for the majority of morbidity and mortality associated with SBS, including central venous catheter infections and PN-induced cholestatic liver dysfunction. There are very few estimates of SBS incidence and mortality in the literature. The epidemiology of SBS is reviewed and the limitations of the published literature are discussed.

Outcomes in children with intestinal failure following listing for intestinal transplant

PURPOSE

The purpose of this study was to describe the population of pediatric patients waiting for intestinal transplant and to evaluate the risk of death or transplant by specific disease states.

METHODS

We studied the United Network for Organ Sharing (UNOS) database (Jan 1,1991 to 5/16/08) for patients 21 years old or younger at first listing for intestinal transplant and examined their age, sex, weight, and diagnoses. Time to list removal was summarized with cumulative incidence curves. Multinomial logistic regression was used to compare relative risk ratios for removal from the list for transplant, death, or other reasons.

RESULTS

We identified 1712 children listed for intestinal transplant (57% male, 51% <1 year, weight 8.1 kg [IQR, 6.1-14.1] at listing). Median age and weight at transplant (n = 852) were 1 year (IQR, 1-5) and 10 kg (IQR, 6.5-16.3). Regression analysis demonstrated significant differences in outcomes among disease conditions (P < .001). Compared to the gastroschisis group, the relative risk ratio for death versus transplant was higher in the necrotizing enterocolitis group (P = .015), lower in the short gut syndrome group (P = .001), and not different in the volvulus group (P = .94) after adjustment for weight and sex.

CONCLUSIONS

We conclude that the relative risk of transplant vs death varies significantly by the disease condition of the patient.

Short bowel syndrome: how short is too short?

Short bowel syndrome (SBS) is the most common cause of intestinal failure. This article discusses the prognostic factors that predict weaning from parenteral nutrition in SBS. The article also delineates an approach to enteral feeding in SBS.

Growth and nutritional aspects of infantile short bowel syndrome for the past 2 decades

PURPOSE

The aim of this retrospective study is to describe characteristics of the first year of infantile short bowel syndrome (SBS), with regard to nutritional correlates and growth. Differences in outcome between decade 1980 (1980 to 1990) and decade 1990 (1990 to 2000) were studied.

METHODS

Children with infantile SBS, who had been admitted in their first year of life between January 1975 and January 2002, were included. Patient characteristics, duration of parenteral nutrition (PN), type of enteral nutrition, and every quarterly term weight and height for age were collected. Data of decade 1980 and decade 1990 were compared, using appropriate statistical analysis.

RESULTS

Twenty-eight patients were identified for decade 1980 vs 62 patients in decade 1990. Length of stay was significantly shorter in decade 1990 (116 vs 182 days; P = .018). Residual bowel length was not significantly longer in the latter decade (74 cm vs 60 cm; not significant [ns]). Mean weight for age (SD score [SDS]) in the first year of SBS in decade 1980 was significantly lower than in decade 1990 (0.9 SDS; P = .035).

CONCLUSIONS

Improved care of patients with SBS and the slightly longer residual bowel length (ns) in decade 1990 resulted in shorter length of stay, shorter duration of PN, and significantly higher SDS for weight for age compared with decade 1980.

Evolution of the immunosuppressive strategies for the intestinal and multivisceral recipients with special reference to allograft immunity and achievement of partial tolerance

Introduction of new innovative immunosuppressive strategies has been the milestone of the recent evolution of intestinal and multivisceral transplantation. With new insights into the mechanisms of organ engraftment and acquired tolerance, the Pittsburgh tolerogenic protocol was recently introduced and consisted of two main therapeutic principles: recipient pretreatment with lymphoid ablating antibodies and minimal post-transplant immunosuppression with tacrolimus monotherapy. The reported herein improved survival and the striking ability to wean immunosuppression among the intestinal and multivisceral recipients pretreated with a single-dose of Thymoglobulin (rATG) or Campath-1H (alemtuzumab) supports our working hypothesis with successful induction of variable tolerance. It is important, however, that careful monitoring of subtle histologic changes in serial endoscopic-guided mucosal biopsies be carried out for early diagnosis of allograft immune activation with prompt restoration of the baseline immunosuppressive therapy. Future scientific discoveries with better understanding of the mechanisms of immune tolerance and clinical introduction of reliable assays will increase the chance and safety of achieving complete tolerance among the intestinal and other solid organ recipients. This review will focus on the historic evolution of the immunosuppressive and other management strategies utilized for the intestinal and multivisceral recipients at the University of Pittsburgh with special reference to allograft immunity and the successful achievement of partial tolerance.

Short bowel syndrome: amelioration of diarrhea after vagotomy and pyloroplasty for peptic hemorrhage

Acute mesenteric ischemia is a rare symptomatic manifestation of arteriosclerosis. Prognosis crucially depends on rapid diagnosis and surgical management to prevent or at least minimize the bowel infarction. The length of the small bowel is considered to be between 3 and 8 m, and a normal bowel function can be maintained even after resection of its one third. But loss of a major part (> 60%) can lead to malnutrition and death. However, patients, who survived an extended intestinal resection due to improved postoperative care (intensive care unit and parenteral nutrition), develop short bowel syndrome. This phenomenon is a medical problem, and several surgical techniques have been used to slow down intestinal transit time or to increase the area of absorption. All these procedures have controversial outcomes and are still on different experimental levels; namely, they cannot be recommended for routine use. In our report of a patient suffering from short bowel syndrome, vagotomy and pyloroplasty were performed to repair a sudden peptic hemorrhage. This operation cured bleeding peptic ulcer and also palliated the diarrhea, a main clinical manifestation of short bowel syndrome. In this study, our aim is to emphasize the favorable clinical outcome of vagotomy concerning a principal manifestation of short bowel syndrome, such as diarrhea. To the best of our knowledge, the present study is the first report showing the vagotomy as a possible procedure for the treatment of diarrhea, although this occurrence has no clear explanation. We also discuss the management of short bowel syndrome.

A national conference to determine research priorities in pediatric solid organ transplantation

The need for evidence-based practice guidelines requires high quality, carefully controlled clinical research trials. This multidisciplinary conference attempted to: identify urgent clinical and research issues, identify obstacles to performing clinical trials, develop concepts for organ-specific and all-organ research and generate a report that would serve as a blueprint for future research initiatives. A few themes became evident. First, young children present a unique immunologic environment which may lead to tolerance, therefore, including young children in immunosuppression withdrawal and tolerance trials may increase the potential benefits of these studies. Second, adolescence poses significant barriers to successful transplantation. Non-adherence may be insufficient to explain poorer outcomes. More studies focused on identification and prevention of non-adherence, and the potential effects of puberty are required. Third, the relatively naive immune system of the child presents a unique opportunity to study primary infections and alloimmune responses. Finally, relatively small numbers of transplants performed in pediatric centers mandate multicenter collaboration. Investment in registries, tissue and DNA repositories will enhance productivity. The past decade has proven that outcomes after pediatric transplantation can be comparable to adults. The pediatric community now has the opportunity to design and complete studies that enhance outcomes for all transplant recipients.

Therapeutic efficacy of intestinal and multivisceral transplantation: survival and nutrition outcome

The clinical introduction of intestinal transplantation has added a new dimension and offered a valid therapeutic option for patients with irreversible intestinal failure. In the year 2000, the Center for Medicare & Medicaid Services (CMS) recognized intestinal, combined liver-intestinal, and multivisceral transplantation as the standard of care for patients with irreversible intestinal and parenteral nutrition (PN) failure. Accordingly, the indications for the procedure are currently limited to those who develop life-threatening PN complications. However, a recent improvement in survival similar to other solid organ transplant recipients should justify lifting the current restricted criteria, and the procedure should be considered before the development of PN failure. Equally important is the awareness of the recent evolution in nutrition management and outcome after transplantation. Early and progressive enteral feeding using a complex polymeric formula is safe and effective after successful transplantation. Full nutrition autonomy is universally achievable among most intestinal and multivisceral recipients, with enjoyment of unrestricted oral diet. Such a therapeutic benefit is commonly maintained among long-term survivors, with full rehabilitation and restoration of quality of life.

Increased iNOS-expressing macrophage in long-term surviving rat small-bowel grafts

BACKGROUND

Inducible nitric oxide synthase (iNOS) produces nitric oxide and modulates many biologic processes critical in the development of rejection; however, its role in chronic rejection (CR) in small-bowel transplantation (SBT) is largely unknown.

METHODS

FK506 prevented acute rejection (AR); however, recipients eventually lost their bowel grafts to CR. Combined FK506 and rapamycin treatment prevented CR, thus leading to long-term graft survival. We investigated iNOS expression in our rat orthotopic SBT CR model.

RESULTS

Histologically, mesentery vascular occlusion and fibrosis, which are hallmarks of CR, were apparent in bowel grafts in an FK506 single-treatment group. In contrast, patients with long-term surviving grafts receiving FK506 and rapamycin developed mild vascular occlusion and fibrosis. Unlike in AR, low iNOS expression, which is associated with decreased macrophage infiltration, was observed in CR grafts. However, iNOS expression and macrophage infiltration was higher in long-term-surviving grafts than CR grafts. Immunofluorescence staining revealed that the majority of macrophages expressed iNOS in long-term surviving grafts.

COMMENTS

Sequential treatment combining FK506 and rapamycin prolonged survival of SBT animals with decreased vasculopathy and collagen deposition of the intestinal grafts. iNOS may play opposing roles in AR and CR in SBT.

Strategies for Epstein–Barr virus monitoring, detection and therapy in post-transplant lymphoproliferative disorder

Epstein–Barr virus (EBV) is a significant cause of morbidity and mortality in solid-organ transplant (SOT) recipients. The most serious complication of EBV infection in this population is post-transplant lymphoproliferative disorder (PTLD). EBV-viral load monitoring can be used to predict those SOT patients at high risk of PTLD, particularly those who are EBV seronegative prior to transplant. Surveillance EBV-load monitoring to inform pre-emptive reduction of immunosuppression has contributed to the decrease in the incidence of PTLD in SOT recipients. The use of the anti-CD20 antibody, rituximab, as a therapeutic agent is increasing, with anecdotal reports of positive outcomes. However, experience to date suggests that the use of this agent may not prevent recurrence of the tumor or improve cell-mediated immune responses to EBV. Future investigation of EBV-specific T-cell responses as an adjunct to monitoring, and the adoptive transfer of EBV-specific cytotoxic T lymphocytes appear likely in future attempts as a means to limit the consequences of EBV infection in the SOT population.

Inhibition of Sonic Hedgehog Signaling Reduces Chronic Rejection and Prolongs Allograft Survival in a Rat Orthotopic Small Bowel Transplantation Model

BACKGROUND

Although acute graft rejection can be successfully controlled by immunosuppressive agents, chronic rejection (CR), which is characterized by arteriosclerosis in the donor organ vessels, is a major hurdle to long-term allograft survival. Sonic hedgehog (Shh), a morphogen critical in embryogenesis, also promotes peripheral immunity, which prompted us to investigate if inhibition of Shh signaling could reduce CR and thereby enhance allograft survival.

METHODS

In a rat orthotopic small bowel transplantation model, FK506 prevented acute rejection; however, recipients eventually lost their grafts by CR. Anti-Shh antibody or isotype control were administered to animals at day 30 postoperatively. Graft survival, tissue fibrosis, vascular occlusion, and expression of vascular endothelial growth factor (VEGF) were investigated.

RESULTS

Immunostaining revealed that Shh and the Hedgehog receptor Patched 1 (Ptc1) are strongly expressed in CR grafts and that Ptc1 expression partially overlapped with that of ED-1, a macrophage marker. In contrast, only minimal expression of Shh and Ptc1 was detected in syngeneic grafts. Grafts survival was significantly prolonged after anti-Shh antibody treatment compared with the immunoglobulin G control (116 vs. 77.5 days). Collagen deposition and vascular occlusion in the mesentery were markedly reduced in recipients of the anti-Shh antibody. Specific transcripts and protein expression for VEGF, which was present mainly in the blood vessels, were reduced.

CONCLUSION

In a rat small bowel transplantation model, anti-Shh antibody treatment reduced CR and prolonged graft survival. These beneficial effects of Shh treatment may occur partly by reducing VEGF expression in the blood vessels of the allografts.

Short bowel syndrome: parenteral nutrition versus intestinal transplantation. Where are we today?

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.

STAT-1 decoy oligonucleotide improves microcirculation and reduces acute rejection in allogeneic rat small bowel transplants

During acute rejection leukocyte-endothelial cell interaction fuelled by costimulatory molecules such as the CD40/CD154 receptor/ligand dyad disrupts microcirculation of the small bowel. Downregulating endothelial CD40 expression by employing a decoy oligonucleotide (dODN) neutralizing the transcription factor signal transducer and activator of transcription-1 (STAT-1) may protect the graft. Therefore allogenic small bowel transplantation was performed in the Brown Norway to Lewis rat model. Graft vessels were pretreated with STAT-1 dODN, mutant control ODN (20 microM) or vehicle (n=8). CD40 antisense ODN and scrambled control ODN-treated transplants served as target control (n=3 each). Intravital microscopy, histology, immunohistochemistry and Western blot analyses were performed 7 days later. Functional capillary density, red blood cell velocity and perfusion index in STAT-1 dODN and CD40 antisense ODN-treated transplants were improved whereas stasis index was reduced. Leukocyte-endothelial cell interaction showed no difference. Histological parameters of rejection, infiltrating CD3-positive cells and apoptotic bodies were also reduced in STAT-1 dODN and CD40 antisense ODN-treated transplants 7 days post-transplantation. CD40 protein abundance was reduced to less than 10% of control in STAT-1 dODN-treated grafts. STAT-1 dODN blockade of CD40 expression improves mucosal perfusion, reduces graft rejection, T-cell infiltration and apoptosis in rat small bowel allografts during acute rejection.

Small intestine transplantation today

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.

Survival and dependence on home parenteral nutrition: experience over a 25-year period in a UK referral centre

BACKGROUND

Home parenteral nutrition (HPN) is the standard treatment for severe intestinal failure in the United Kingdom.

AIM

To review long-term survival and ongoing HPN dependence of patients receiving HPN treated at a specialist UK referral centre.

METHODS

Medical records of patients commenced on HPN between 1979 and 2003 were reviewed retrospectively. Regression analysis was employed to identify factors associated with poor prognosis.

RESULTS

Case notes of 188 patients were reviewed. Overall probability of survival was 86%, 77%, 73% and 71% at 1, 3, 5 and 10 years after starting treatment. In multivariate analysis, association was seen between mechanism of intestinal failure and survival: short bowel syndrome associated with a favourable prognosis, and intestinal dysfunction, dysmotility and obstruction with poorer prognoses. There was an association between increasing age and poor prognosis, but increased mortality was also seen in the youngest age groups. Only 9% of deaths were due to complications of HPN. Continued HPN dependence was 89%, 87%, 84% and 84% at 1, 3, 5 and 10 years in survivors.

CONCLUSIONS

Long-term survival of patients receiving HPN remains better than that reported after intestinal transplantation. Mortality predominantly relates to underlying disease rather than complications of HPN.