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Di Cocco P, Martinino A, Lian A, Johnson J, Spaggiari M, Tzvetanov I, Benedetti E. Indications for Multivisceral Transplantation: A Systematic Review. Gastroenterol Clin North Am 2024; 53:245-264. [PMID: 38719376 DOI: 10.1016/j.gtc.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Consensus remains elusive in the definition and indications of multivisceral transplantation (MVT) within the transplant community. MVT encompasses transplantation of all organs reliant on the celiac artery axis and the superior mesenteric artery in different combinations. Some institutions classify MVT as involving the grafting of the stomach or ascending colon in addition to the jejunoileal complex. MVT indications span a wide spectrum of conditions, including tumors, intestinal dysmotility disorders, and trauma. This systematic review aims to consolidate existing literature on MVT cases and their indications, providing an organizational framework to comprehend the current criteria for MVT.
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Affiliation(s)
- Pierpaolo Di Cocco
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Alessandro Martinino
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA.
| | - Amy Lian
- University of Illinois at Chicago College of Medicine, Chicago, IL, USA
| | - Jess Johnson
- University of Illinois at Chicago College of Medicine, Chicago, IL, USA
| | - Mario Spaggiari
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Ivo Tzvetanov
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Enrico Benedetti
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
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Prathapan KM, King DE, Raghu VK, Ackerman K, Presel T, Yaworski JA, Ganoza A, Bond G, Sevilla WMA, Rudolph JA, Alissa F. Megacystis Microcolon Intestinal Hypoperistalsis Syndrome: A Case Series With Long-term Follow-up and Prolonged Survival. J Pediatr Gastroenterol Nutr 2021; 72:e81-e85. [PMID: 33264186 PMCID: PMC9124153 DOI: 10.1097/mpg.0000000000003008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Describe clinical characteristics, management, and outcome in a cohort of megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS) patients. METHODS We conducted a retrospective chart review of MMIHS patients followed at a large transplant and intestinal rehabilitation center over a period of 17 years. RESULTS We identified 25 patients with MMIHS (68% girls, 13 transplanted). One transplanted and 1 nontransplanted patient were lost to follow-up. We estimated 100, 100, and 86% for 5-, 10-, and 20-year survival, respectively, with only 1 death. Of the 22 patients alive at the time of study (11 transplanted, 11 nontransplanted), median age was 9.2 years (range 2.7-22.9 years). Longest posttransplant follow-up was 16 years. Seventeen patients had available prenatal imaging reports; all showed distended bladder. Eight had genetic testing (5, ACTG2; 2, MYH11; 1, MYL9). Almost all patients had normal growth with median weight z-score -0.77 (interquartile range -1.39 to 0.26), height z score -1.2 (-2.04 to -0.48) and body mass index z-score 0.23 (-0.37 to 0.93) with no statistical difference between transplanted and nontransplanted patients. All nontransplanted patients were on parenteral nutrition with minimal/no feeds, and all except 1 of the transplanted patients were on full enteral feeds. Recent average bilirubin, INR, albumin, and creatinine fell within the reference ranges. CONCLUSIONS This is the largest single-center case series with the longest duration of follow-up for MMIHS patients. In the current era of improved intestinal rehabilitation and transplantation, MMIHS patients have excellent outcomes in survival, growth, and liver function. This observation contradicts previous reports and should alter counselling and management decisions in these patients at diagnosis.
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Affiliation(s)
- Krishnapriya Marangattu Prathapan
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Dale E. King
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Vikram Kalathur Raghu
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Kimberly Ackerman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Tracey Presel
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Jane Anne Yaworski
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Armando Ganoza
- Hillman Center for Pediatric Liver Transplantation, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Geoffrey Bond
- Hillman Center for Pediatric Liver Transplantation, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Wednesday Marie A. Sevilla
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Jeffrey A. Rudolph
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Feras Alissa
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA
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Megacystis-Microcolon-Intestinal Hypoperistalsis Syndrome (MMIHS): Series of 4 Cases Caused by Mutation of ACTG2 (Actin Gamma 2, Smooth Muscle) Gene. Case Rep Gastrointest Med 2021; 2021:6612983. [PMID: 33859849 PMCID: PMC8026316 DOI: 10.1155/2021/6612983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 03/16/2021] [Accepted: 03/22/2021] [Indexed: 11/17/2022] Open
Abstract
MMIHS, also known as Berdon's syndrome, is a rare disease that belongs to primary causes of CIPOS (chronic intestinal pseudoobstruction syndrome). Clinical characteristics of MMIHS are differential, but we come across the following classic symptoms: disorders of intestinal peristalsis, microcolon, and megacystis. In this article, we present a series of 4 patients with Berdon's syndrome, in whom we managed to identify the genetic causes of MMIHS. All infants showed clinical features of bowel obstruction and dysfunction of the urinary system after birth. Two of them also manifested disorders from other systems. The prognosis for these patients is poor, but a constant betterment of management in MMIHS, in which the leading role plays TPN (total parental nutrition), causes improvement of patients' survival.
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Twenty Years of Gut Transplantation for Chronic Intestinal Pseudo-obstruction: Technical Innovation, Long-term Outcome, Quality of Life, and Disease Recurrence. Ann Surg 2021; 273:325-333. [PMID: 31274659 DOI: 10.1097/sla.0000000000003265] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To define long-term outcome, predictors of survival, and risk of disease recurrence after gut transplantation (GT) in patients with chronic intestinal pseudo-obstruction (CIPO). BACKGROUND GT has been increasingly used to rescue patients with CIPO with end-stage disease and home parenteral nutrition (HPN)-associated complications. However, long-term outcome including quality of life and risk of disease recurrence has yet to be fully defined. METHODS Fifty-five patients with CIPO, 23 (42%) children and 32 (58%) adults, underwent GT and were prospectively studied. All patients suffered gut failure, received HPN, and experienced life-threatening complications. The 55 patients received 62 allografts; 43 (67%) liver-free and 19 (33%) liver-contained with 7 (13%) retransplants. Hindgut reconstruction was adopted in 1993 and preservation of native spleen was introduced in 1999. Immunosuppression was tacrolimus-based with antilymphocyte recipient pretreatment in 41 (75%). RESULTS Patient survival was 89% at 1 year and 69% at 5 years with respective graft survival of 87% and 56%. Retransplantation was successful in 86%. Adults experienced better patient (P = 0.23) and graft (P = 0.08) survival with lower incidence of post-transplant lymphoproliferative disorder (P = 0.09) and graft versus host disease (P = 0.002). Antilymphocyte pretreatment improved overall patient (P = 0.005) and graft (P = 0.069) survival. The initially restored nutritional autonomy was sustainable in 23 (70%) of 33 long-term survivors with improved quality of life. The remaining 10 recipients required reinstitution of HPN due to allograft enterectomy (n = 3) or gut dysfunction (n = 7). Disease recurrence was highly suspected in 4 (7%) recipients. CONCLUSIONS GT is life-saving for patients with end-stage CIPO and HPN-associated complications. Long-term survival is achievable with better quality of life and low risk of disease recurrence.
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Muto M, Matsufuji H, Taguchi T, Tomomasa T, Nio M, Tamai H, Tamura M, Sago H, Toki A, Nosaka S, Kuroda T, Yoshida M, Nakajima A, Kobayashi H, Sou H, Masumoto K, Watanabe Y, Kanamori Y, Hamada Y, Yamataka A, Shimojima N, Kubota A, Ushijima K, Haruma K, Fukudo S, Araki Y, Kudo T, Obata S, Sumita W, Watanabe T, Fukahori S, Fujii Y, Yamada Y, Jimbo K, Kawai F, Fukuoka T, Onuma S, Morizane T, Ieiri S, Esumi G, Jimbo T, Yamasaki T. Japanese clinical practice guidelines for allied disorders of Hirschsprung's disease, 2017. Pediatr Int 2018; 60:400-410. [PMID: 29878629 DOI: 10.1111/ped.13559] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 02/27/2018] [Accepted: 03/07/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite the presence of ganglion cells in the rectum, some patients have symptoms similar to those of Hirschsprung's disease. A consensus has yet to be established regarding the terminology for these diseases. We defined this group of diseases as "allied disorders of Hirschsprung's disease" and compiled these guidelines to facilitate accurate clinician diagnosis and provide appropriate treatment strategies for each disease. METHODS These guidelines were developed using the methodologies in the Medical Information Network Distribution System (MINDS). Of seven allied disorders, isolated hypoganglionosis; megacystis-microcolon-intestinal hypoperistalsis syndrome; and chronic idiopathic intestinal pseudo-obstruction were selected as targets of clinical questions (CQ). In a comprehensive search of the Japanese- and English-language articles in PubMed and Ichu-Shi Web, 836 pieces of evidence related to the CQ were extracted from 288 articles; these pieces of evidence were summarized in an evidence table. RESULTS We herein outline the newly established Japanese clinical practice guidelines for allied disorders of Hirschsprung's disease. Given that the target diseases are rare and intractable, most evidence was drawn from case reports and case series. In the CQ, the diagnosis, medication, nutritional support, surgical therapy, and prognosis for each disease are given. We emphasize the importance of full-thickness intestinal biopsy specimens for the histopathological evaluation of enteric ganglia. Considering the practicality of the guidelines, the recommendations for each CQ were created with protracted discussions among specialists. CONCLUSIONS Clinical practice recommendations for allied disorders of Hirschprung's disease are given for each CQ, along with an assessment of the current evidence. We hope that the information will be helpful in daily practice and future studies.
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Affiliation(s)
- Mitsuru Muto
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Hiroshi Matsufuji
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Tomoaki Taguchi
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Takeshi Tomomasa
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Masaki Nio
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Hiroshi Tamai
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Masanori Tamura
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Haruhiko Sago
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Akira Toki
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Shunsuke Nosaka
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Tatsuo Kuroda
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Masahiro Yoshida
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Atsushi Nakajima
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Hiroyuki Kobayashi
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Hideki Sou
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Kouji Masumoto
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Yoshio Watanabe
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Yutaka Kanamori
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Yoshinori Hamada
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Atsuyuki Yamataka
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Naoki Shimojima
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Akio Kubota
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Kosuke Ushijima
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Ken Haruma
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Shin Fukudo
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Yuko Araki
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Takahiro Kudo
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Satoshi Obata
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Wataru Sumita
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Toshihiko Watanabe
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Suguru Fukahori
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Yoshimitsu Fujii
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Yoshiyuki Yamada
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Keisuke Jimbo
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Fujimi Kawai
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Tomoya Fukuoka
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Shinsuke Onuma
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Toshio Morizane
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Satoshi Ieiri
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Genshiro Esumi
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Takahiro Jimbo
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
| | - Tomoko Yamasaki
- The guideline establishment group for allied disorders of Hirschsprung's disease, Science Research, Ministry of Health Labour and Welfare, Fukuoka, Japan
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Soltys KA, Bond G, Sindhi R, Rassmussen SK, Ganoza A, Khanna A, Mazariegos G. Pediatric intestinal transplantation. Semin Pediatr Surg 2017; 26:241-249. [PMID: 28964480 DOI: 10.1053/j.sempedsurg.2017.07.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The field of intestinal transplantation has experienced dramatic growth since the first reported cases 3 decades ago. Improvements in operative technique, donor assessment and immunosuppressive protocols have afforded children who suffer from life-threatening complications of intestinal failure a chance at long-term survival. As experience has grown, newer diseases, with more systemic manifestations have arisen as potential indications for transplant. After discussing the historical developments of intestinal transplant as a backdrop, this review focuses on the specific pre-operative indications for transplant as well as the great success that intestinal rehabilitation has witnessed over the past decade. A detailed discussion of evolution of immunosuppressive strategies is followed a general review of the common infectious complications experienced by children after intestinal transplant as well as the current long- and short-term results, including a section on new research on the quality of life in this challenging population of patients.
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Affiliation(s)
- Kyle A Soltys
- The Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, 4401 Penn Ave, 6 FP, Pittsburgh, PA 15224.
| | - Geoff Bond
- The Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, 4401 Penn Ave, 6 FP, Pittsburgh, PA 15224
| | - Rakesh Sindhi
- The Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, 4401 Penn Ave, 6 FP, Pittsburgh, PA 15224
| | | | - Armando Ganoza
- The Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, 4401 Penn Ave, 6 FP, Pittsburgh, PA 15224
| | - Ajai Khanna
- The Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, 4401 Penn Ave, 6 FP, Pittsburgh, PA 15224
| | - George Mazariegos
- The Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, 4401 Penn Ave, 6 FP, Pittsburgh, PA 15224
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De Sousa J, Upadhyay V, Stone P. Megacystis Microcolon Intestinal Hypoperistalsis Syndrome: Case Reports and Discussion of the Literature. Fetal Diagn Ther 2015; 39:152-7. [DOI: 10.1159/000442050] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 10/26/2015] [Indexed: 11/19/2022]
Abstract
Megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS) is a rare intestinal dysmotility condition that also involves a dilated urinary bladder. It was believed to be an autosomal recessive condition, but genetic studies have suggested possibly an autosomal dominant inheritance pattern. Prenatal diagnosis can be challenging, but MRI and amniotic fluid/digestive fluid studies may be complementary investigations to improve diagnostic accuracy. Prognosis of MMIHS is generally poor and treatment is mostly supportive. To date, bowel transplantation remains the only viable treatment to restore bowel motility. Here we present two additional cases to contribute towards the scant literature on this condition.
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Megacystis microcolon intestinal hypoperistalsis syndrome: A report of a nationwide survey in Japan. J Pediatr Surg 2015; 50:2048-50. [PMID: 26413901 DOI: 10.1016/j.jpedsurg.2015.08.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 08/24/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS) is a rare condition with a poor outcome. A nationwide survey was conducted to identify the clinical features and outcomes of MMIHS in Japan. METHODS Data were collected via a questionnaire, which was sent to 353 pediatric/pediatric surgical departments in Japan. RESULTS Of the 28 patients registered as having a certain diagnosis of MMIHS, 19 (male/female, 3/16) patients were analyzed. All of the patients developed functional bowel obstruction in the neonatal period and showed a distended bladder and microcolon in the radiological examination. A histopathology assessment of the full-thickness of intestinal specimens showed no pathological abnormalities in all patients. Although various medications were given, the patients did not show significant improvement. Drainage stomas were created in the jejunum (n=11) and colon (n=5). Sixteen patients were maintained by parenteral nutrition (PN). Nine patients died of sepsis or liver failure. The five- and ten-year survival rates were 63% and 57%, respectively. CONCLUSIONS MMIHS patients developed severe functional intestinal obstruction in the neonatal period and had no specific therapeutic intervention. The majority of MMIHS patients required long-term PN. Small bowel or multivisceral transplantation may be necessary to improve the outcome of this condition.
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Mc Laughlin D, Puri P. Familial megacystis microcolon intestinal hypoperistalsis syndrome: a systematic review. Pediatr Surg Int 2013; 29:947-51. [PMID: 23955298 DOI: 10.1007/s00383-013-3357-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS) is a rare and severe disorder of functional obstruction affecting bladder and bowel, usually diagnosed in the neonatal period. Over 230 cases have been reported since Berdon and colleagues first described this clinical entity in 1976. The exact pathogenesis of MMIHS is unknown. Familial occurrence of MMIHS has been reported and could offer insight into the aetiology of this disease. The purpose of this study was to systematically review the published literature for the evidence of familial MMIHS and to characterise these presentations. METHODS A literature search was performed using the keywords "megacystis microcolon intestinal hypoperistalsis" (1976-2013). Retrieved articles, including additional studies from reference lists, were reviewed for consanguinity between parents and recurrence of MMIHS between siblings. Data were extracted for cases where familial MMIHS was present. RESULTS A total of 47 patients were reported in which familial MMIHS was likely or confirmed. 15 sibling sets were definitively diagnosed with MMIHS (14 pairs and one set of three siblings). Four further index patients with a confirmed diagnosis and also one of the sibling pairs were reported to have a sibling in which MMIHS was probable. Consanguinity between parents was present in four of the confirmed sibling sets and in an additional seven individual cases. The outcome for familial MMIHS is generally poor. Multiple sibling fatalities were frequent and in only one family were both siblings' survivors at the time of reporting. CONCLUSION Consanguinity between parents and recurrence in siblings indicate that MMIHS is inherited in an autosomal recessive manner. With the advent of next generation sequencing, these familial clusters may be key to determining the genetic basis for MMIHS.
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Affiliation(s)
- Danielle Mc Laughlin
- National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland
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10
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Abstract
"Variants of Hirschsprung's disease" are conditions that clinically resemble Hirschsprung's disease (HD), despite the presence of ganglion cells in rectal suction biopsies. The diagnosis and management of these patients can be challenging. Specific histological, immunohistochemical and electron microscopic investigations are required to characterize this heterogeneous group of functional bowel disorders. Variants of HD include intestinal neuronal dysplasia, intestinal ganglioneuromatosis, isolated hypoganglionosis, immature ganglia, absence of the argyrophil plexus, internal anal sphincter achalasia and congenital smooth muscle cell disorders such as megacystis microcolon intestinal hypoperistalsis syndrome. This review article systematically classifies variants of HD based on current diagnostic criteria with an additional focus on pathogenesis, epidemiology, clinical presentation, management and outcome.
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11
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Hiradfar M, Shojaeian R, Dehghanian P, Hajian S. Megacystis microcolon intestinal hypoperistalsis syndrome. BMJ Case Rep 2013; 2013:bcr-2012-007524. [PMID: 23729700 DOI: 10.1136/bcr-2012-007524] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS) is a multisystemic disorder in which impaired intestinal motor activity causes recurrent symptoms of intestinal obstruction in the absence of mechanical occlusion, associated with bladder distention without distal obstruction of the urinary tract. MMIHS and prune belly syndrome may overlap in most of the clinical features and discrimination of these two entities is important because the prognosis, management and consulting with parents are completely different. MMIHS outcome is very poor and in this article we present two neonates with MMIHS that both died in a few days.
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Affiliation(s)
- Mehran Hiradfar
- Department of Pediatric Surgery, Mashhad University of Medical Sciences, Mashhad, Iran
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12
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Ballisty MM, Braithwaite KA, Shehata BM, Dickson PN. Imaging findings in megacystis-microcolon-intestinal hypoperistalsis syndrome. Pediatr Radiol 2013; 43:454-9. [PMID: 22926452 DOI: 10.1007/s00247-012-2479-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Revised: 06/17/2012] [Accepted: 07/06/2012] [Indexed: 11/28/2022]
Abstract
Megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS) is a rare and frequently lethal form of severe functional intestinal obstruction more commonly found in girls. Imaging features characteristic of this disease include a large dilated bladder, microcolon and intestinal dysmotility. Additional imaging findings may include intestinal malrotation, hydronephrosis and vesicoureteral reflux. It is usually fatal in the first year of life. Because presenting clinical and imaging features can mimic other causes of neonatal bowel obstruction, we compiled examples of this disorder to help the pediatric radiologist recognize imaging findings associated with MMIHS and aid in the development of a long-term management plan and in counseling the family regarding implications of this disorder. We reviewed recent and historical literature relevant to MMIHS and present the imaging and clinical features of four patients with MMIHS treated at our institution as examples of this uncommon disorder.
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Affiliation(s)
- Marianne M Ballisty
- Department of Radiology and Imaging Sciences, Children's Healthcare of Atlanta, Emory University, 1405 Clifton Road NE, Atlanta, GA 30322, USA.
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Megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS): report of a case with prolonged survival and literature review. J Pediatr Urol 2013; 9:e12-8. [PMID: 22749573 DOI: 10.1016/j.jpurol.2012.05.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2012] [Accepted: 05/31/2012] [Indexed: 10/28/2022]
Abstract
Megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS) was first described in 1976. A rare congenital autosomal recessive alteration that predominantly affects females (4:1 ratio), it is characterized by the presence of distended bladder (without distal urinary tract obstruction), microcolon, and decreased or absent intestinal peristalsis. Inconsistent and non-specific histological changes affecting the bladder and intestinal smooth muscle, and intrinsic innervations, have been reported most frequently. MMIHS usually has a fatal prognosis in the first year of life; nevertheless there are some case reports of longer survival. Here is presented the case report of a boy with a diagnosis of MMIHS who has achieved prolonged survival, followed by a review of the literature.
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Huang CM, Tseng SH, Weng CC, Chen Y. Isolated intestinal transplantation for megacystis microcolon intestinal hypoperistalsis syndrome: case report. Pediatr Transplant 2013; 17:E4-8. [PMID: 23167913 DOI: 10.1111/petr.12019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2012] [Indexed: 12/14/2022]
Abstract
MMIHS is a rare congenital disease. It is characterized by distended urinary bladder, small colon and intestinal hypoperistalsis, or aperistalsis with normal morphology. There is no specific treatment for MMIHS, and most patients have to be maintained by TPN, which frequently causes TPN-related liver failure, loss of venous access, or catheter-related sepsis. The prognosis of patients with MMIHS is poor, and most patients die early. Multivisceral transplantation including stomach, duodenum, intestine, and liver has been used for the treatment of patients with MMIHS because these patients often have liver failure. We report an eight-yr-old patient with MMIHS who was treated with isolated intestinal transplantation. She had completely oral intake during the four yr of follow-up. The experience in this case suggests isolated intestinal transplantation may be indicated in selected cases with MMIHS.
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Affiliation(s)
- Chen-Ming Huang
- Division of Pediatric Surgery, Department of Surgery, Far Eastern Memorial Hospital, New Taipei, Taiwan
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15
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Abstract
PURPOSE Megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS) is a rare and the most severe form of functional intestinal obstruction in the newborn. This congenital condition is associated with non-obstructed urinary bladder, microcolon and decreased or absent intestinal peristalsis. This study was designed to determine the incidence and outcome of MMIHS. METHODS A systematic review of the literature (1976-2011) was performed for key words "megacystis microcolon intestinal hypoperistalsis". Resulting publications were reviewed for epidemiology and outcome. Reference lists were screened for additional cases. RESULTS A total number of 227 MMIHS cases were reported from 1976 to 2011. A clear preponderance for female infants was found (female 70.6 vs. male 29.4%). One or more surgical interventions were reported in 115 patients (including gastrostomy, ileostomy, jejunostomy, segmental resections of small bowel, adhesiolysis and internal sphincter myectomy). For decompression of the megacystis, vesicostomy was performed in 41 patients. Outcome was reported in a total of 218 patients. Survival rate was 19.7% (survivors: n = 43, non-survivors: n = 175), the oldest survivor being 24 years old. The vast majority of the surviving patients had to be maintained by total or partial parenteral nutrition (TPN). Main causes of death were sepsis, malnutrition and multiple organ failure. Twelve multivisceral transplantations have been reported to date in patients with MMIHS. The majority of the survivors are reported to be free of parenteral nutrition and show improving gastric emptying. However, intermittent catheterisation remains obligatory due to persistent bladder dysfunction. CONCLUSIONS The survival in MMIHS in recent years has improved. The majority of survivors are either maintained by TPN or have undergone multiorgan transplantations.
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Megacystis-microcolon-intestinal hypoperistalsis syndrome: a case report. Gastroenterol Res Pract 2009; 2009:282753. [PMID: 19794822 PMCID: PMC2753778 DOI: 10.1155/2009/282753] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Accepted: 07/14/2009] [Indexed: 11/23/2022] Open
Abstract
Megacystis Microcolon Intestinal Hypoperistalsis Syndrom (MMIHS) is a quite rare congenital and fatal disease which was firstly defined by Berdon and his colleagues. It
appears through a widely enlarged bladder and microcolon and its cause is unknown (Berdon et al., 1976; Carmelo et al., 2005; Makhija et al., 1999; Loening-Baucke and Kimura 1999; Redman et al., 1984; Hsu et al., 2003; Yigit et al., 1996; Srikanth et al., 1993).
The disease is found in females three or four times more than in males (Srikanth et al., 1993; Sen et al., 1993; Hirato et al., 2003). Most of the
cases die within the early months of their lives (Yigit et al., 1996; Srikanth et al., 1993; Sen et al., 1993; Hirato et al., 2003). We present the case of a female
newborn with antenatal ultrasound revealing intestinal mass and bilateral
hydroureteronephrosis. The case was admitted for intestinal obstruction after birth.
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17
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Verbruggen SCAT, Wijnen RMH, Berg PVD. Megacystis-microcolon-intestinal hypoperistalsis syndrome: a case report. J Matern Fetal Neonatal Med 2009. [DOI: 10.1080/jmf.16.2.140.141] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- SCAT Verbruggen
- Department of Pediatrics Erasmus MC Sophia Children's Hospital Rotterdam The Netherlands
| | - RMH Wijnen
- Department of Pediatric Surgery UMC St. Radboud Nijmegen The Netherlands
| | - P van den Berg
- Department of Gynecology UMC St. Radboud Nijmegen The Netherlands
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18
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Giovanelli M, Gupte GL, Sharif K, Mayer DA, Mirza DF. Chronic rejection after combined liver and small bowel transplantation in a child with chronic intestinal pseudo-obstruction: a case report. Transplant Proc 2008; 40:1763-7. [PMID: 18589190 DOI: 10.1016/j.transproceed.2008.01.066] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2007] [Accepted: 01/16/2008] [Indexed: 12/27/2022]
Abstract
An 11-year-old boy with irreversible intestinal failure secondary to chronic intestinal pseudo-obstruction (CIPO) and intestinal failure-associated liver disease (IFALD) underwent a combined en bloc reduced liver and small bowel transplantation. He was discharged home after 9 weeks on full oral intake without requiring intravenous nutritional or fluid supplementation. The first episode of mild acute rejection, which occurred 18 months after transplantation, was successfully treated with steroids. An episode of rotavirus gastroenteritis led to severe exfoliative rejection of the bowel graft, which was resistant to steroid and Infliximab treatment but responded to OKT3. There was associated Epstein-Barr virus viremia with no evidence of posttransplant lymphoproliferative disease. Another episode of moderate to severe acute liver rejection occurred 5 months later. At the same time, multiple biliary strictures were diagnosed and treated. Persistent clinical symptoms of abdominal pain and increased stomal output as well as atrophy of the ileal mucosa on several biopsies, suggested the possibility of chronic rejection (CR). A second combined whole liver and small bowel transplant was performed. The diagnosis of CR was confirmed on histology of the explanted graft. The postoperative course was severely complicated and 71 days after the retransplantation, the boy died because of respiratory failure and multiorgan failure. In summary, intestinal transplantation can be successfully performed in children with CIPO, giving them the opportunity to be free from total parenteral nutrition. As survival following intestinal transplantation continues to improve, the problem of CR has become increasingly important and the only treatment available is retransplantation, which is associated with poor outcomes.
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Affiliation(s)
- M Giovanelli
- Department of General Surgery III, Liver and Transplant Unit, Ospedali Riuniti di Bergamo, Italy.
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19
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Raofi V, Beatty E, Testa G, Abcarian H, Oberholzer J, Sankary H, Grevious M, Benedetti E. Combined living-related segmental liver and bowel transplantation for megacystis-microcolon-intestinal hypoperistalsis syndrome. J Pediatr Surg 2008; 43:e9-e11. [PMID: 18280270 DOI: 10.1016/j.jpedsurg.2007.09.073] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2007] [Accepted: 09/16/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS) is the most severe form of functional intestinal obstruction in the newborn. To date, multivisceral transplantation has been the only accepted treatment modality for these patients, and the results have met with marginal success. We report the first case of a patient affected by MMIHS and cholestatic liver failure treated by a combined living-related liver and intestinal transplant (CLRLITx). CASE REPORT The patient was a 1-year-old Hispanic girl born with MMIHS and maintained on total parenteral nutrition since birth. Once liver failure developed, she was referred for evaluation for possible CLRLITx. The patient's mother volunteered as the donor. The left lateral segment was used for the liver transplant. The intestinal graft consisted of the terminal 180 cm of the ileum with a single vascular pedicle. Initially, the patient continued to have severe gastroparesis; however, by 8 months posttransplant, stomach function had returned to normal. Currently, at 2 years posttransplant, she is tolerating an oral diet with gastric tube supplementation. Results of absorption studies are within normal, and she has shown catch-up growth. CONCLUSION A CLRLITx can be a viable alternative for infants diagnosed with MMIHS. This procedure can help avoid the 25% wait-list mortality for children who are in need of a combined transplant.
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Affiliation(s)
- Vandad Raofi
- Division of Transplant Surgery, Department of Surgery (M/C 958), University of Illinois College of Medicine, Chicago, IL 60612, USA.
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20
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Narayanan M, Murphy MS, Ainsworth JR, Arul GS. Mydriasis in association with MMIHS in a female infant: evidence for involvement of the neuronal nicotinic acetylcholine receptor. J Pediatr Surg 2007; 42:1288-90. [PMID: 17618899 DOI: 10.1016/j.jpedsurg.2007.02.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We report a case of megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS), occurring in association with mydriasis, in a female infant born to consanguineous Asian parents. This association has not previously been reported and is of interest because mydriasis has been found in a murine MMIHS model produced by knockout of the genes coding for the alpha3 subunit or the beta2 and beta4 subunits of the neuronal nicotinic acetylcholine receptor. This may provide an important clue to the genetic basis of MMIHS in humans.
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Affiliation(s)
- M Narayanan
- Department of Paediatric Surgery, Birmingham Children's Hospital, B4 6NH Birmingham, UK
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21
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Goulet O, Ruemmele F. Causes and management of intestinal failure in children. Gastroenterology 2006; 130:S16-28. [PMID: 16473066 DOI: 10.1053/j.gastro.2005.12.002] [Citation(s) in RCA: 241] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2004] [Accepted: 06/06/2005] [Indexed: 12/28/2022]
Abstract
Intestinal failure is a condition requiring the use of parenteral nutrition as long as it persists. Causes of severe protracted intestinal failure include short bowel syndrome, congenital diseases of enterocyte development, and severe motility disorders (total or subtotal aganglionosis or chronic intestinal pseudo-obstruction syndrome). Intestinal failure may be irreversible in some patients, thus requiring permanent parenteral nutrition. Liver disease may develop with subsequent end-stage liver cirrhosis in patients with intestinal failure as a consequence of both underlying digestive disease and unadapted parenteral nutrition. Death will occur if combined liver-intestine transplantation is not performed. Catheter-related sepsis and/or extensive vascular thrombosis may impede the continuation of a safe and efficient parenteral nutrition and may also require intestinal transplantation in some selected cases. Thus management of patients with intestinal failure requires an early recognition of the condition and the analysis of its risk of irreversibility. Timing of referral for intestinal transplantation remains a crucial issue. As a consequence, management should include therapies adapted to each stage of intestinal failure based on a multidisciplinary approach in centers involving pediatric gastroenterology, parenteral nutrition expertise, home parenteral nutrition program, pediatric surgery, and liver intestinal transplantation program.
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Affiliation(s)
- Olivier Goulet
- Integrated Program of Intestinal Failure, Home Parenteral Nutrition and Intestinal Transplantation, National Reference Center for Rare Digestive Disease, Hôpital Necker-Enfants Malades, Université Reni Descartes, Paris, France.
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22
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Loinaz C, Rodríguez MM, Kato T, Mittal N, Romaguera RL, Bruce JH, Nishida S, Levi D, Madariaga J, Tzakis AG. Intestinal and multivisceral transplantation in children with severe gastrointestinal dysmotility. J Pediatr Surg 2005; 40:1598-604. [PMID: 16226991 DOI: 10.1016/j.jpedsurg.2005.06.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND/PURPOSE Severe gastrointestinal dysmotility (GID) impairs patients' quality of life and is almost uniformly fatal after complications of parenteral nutrition. Intestinal and multivisceral transplants have been used as alternative treatment of these disorders. We studied patients with GID treated with transplantation in our center, and reviewed their outcome to determine the therapeutic efficacy of multivisceral transplants. METHODS The transplant database was searched for patients with GID from 1994 to 2001. We excluded patients with Hirschsprung disease, scleroderma, and diabetic enteropathy. We reviewed explanted organs, histochemistry, and immunohistochemistry and classified cases by etiology. RESULTS We selected 12 children with GID from 124 patients transplanted. Nine presented before 1 year and 3 started with symptoms between 2 and 8 years. By combined clinical and histopathological features, 6 were classified as megacystis microcolon intestinal hypoperistalsis syndrome, 4 as chronic idiopathic intestinal pseudoobstruction, and 2 as intestinal neuronal dysplasias. Six patients died during the follow-up from 21 to 546 days after transplant. The Kaplan-Meier actuarial survival rates were 66.7% at 1 year and 50% at 3 years. CONCLUSIONS Multivisceral transplantation is a valuable therapeutic alternative for children with severe GID who cannot be adequately managed with parenteral nutrition.
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Affiliation(s)
- Carmelo Loinaz
- Department of Surgery, 12 de Octubre Hospital, Complutense University of Madrid, Madrid 28041, Spain
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23
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Kato T, Gaynor JJ, Selvaggi G, Mittal N, Thompson J, McLaughlin GE, Nishida S, Moon J, Levi D, Madariaga J, Ruiz P, Tzakis A. Intestinal transplantation in children: a summary of clinical outcomes and prognostic factors in 108 patients from a single center. J Gastrointest Surg 2005; 9:75-89; discussion 89. [PMID: 15623448 DOI: 10.1016/j.gassur.2004.10.012] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We performed 124 intestinal transplants on 108 children (median age, 1.5 years) since 1994. Initial graft types included isolated intestine (I) (n=26), liver and intestine (LI) (n=26), multivisceral (MV) (n=50), and multivisceral without liver (MMV) (n=6). Four groups were defined by type of induction therapy: none, OKT3, or cyclophosphamide (August 1994-December 1997, n=25), early experience with daclizumab (January 1998-December 2000, n=26), recent experience with daclizumab (January 2001-April 2004, n=40), and Campath-1H (January 2001-April 2004, n=17). Actuarial patient survival at 1 year for groups 1-4 was 44%+/-10%, 54%+/-10%, 83%+/-6%, and 41%+/-12%, respectively, with group 3 having the most favorable survival (P=0.0004). Using Cox stepwise regression, the hazard rate of developing severe rejection was significantly higher in patients with transplant type I or LI (P=0.0002), with no difference between these groups (P=0.24) but a significantly higher rate for LI versus MV (P=0.005). Three factors associated with improved patient survival were recipient of MV or MMV (P=0.008), age at transplantation greater than 1 year (P=0.01), and use of daclizumab (P=0.0006). Cause-specific hazard analysis revealed a decreased rate of rejection-related mortality for recipients of MV or MMV (P=0.0007), whereas age greater than 1 year indicated a lower rate of infection-related mortality (P=0.0009). Pediatric intestinal transplantation provides an increasingly realistic chance of survival, particularly with the more recent use of daclizumab and multivisceral transplantation. A protective effect of multivisceral transplantation appears to exist with respect to the development of severe rejection.
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Affiliation(s)
- Tomoaki Kato
- Division of Transplantation, University of Miami, School of Medicine, Miami, Florida 33136, USA.
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24
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Levin TL, Soghier L, Blitman NM, Vega-Rich C, Nafday S. Megacystis-microcolon-intestinal hypoperistalsis and prune belly: overlapping syndromes. Pediatr Radiol 2004; 34:995-8. [PMID: 15289943 DOI: 10.1007/s00247-004-1260-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2004] [Revised: 05/27/2004] [Accepted: 06/04/2004] [Indexed: 10/26/2022]
Abstract
Megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS) is a rare, often fatal condition. Infants present with a functional obstruction of the gastrointestinal tract (GI), malrotation, microcolon, and a large nonobstructed bladder. Several features common to both MMIHS and Eagle-Barrett or prune belly syndrome (PBS) include hydronephrosis, bladder distension and laxity of the abdominal wall musculature. Additionally, MMIHS and PBS have been reported in the same family, suggesting the possibility of a common pathogenesis. MMIHS usually presents in female infants. We present a male infant diagnosed with both MMIHS and PBS. This is a unique case in which both MMIHS and true PBS are present in the same infant.
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Affiliation(s)
- Terry L Levin
- Department of Radiology, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467-2490, USA.
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25
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Bond GJ, Reyes JD. Intestinal transplantation for total/near-total aganglionosis and intestinal pseudo-obstruction. Semin Pediatr Surg 2004; 13:286-92. [PMID: 15660322 DOI: 10.1053/j.sempedsurg.2004.10.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Whether from anatomical short gut (such as after resection of extensive intestinal aganglionosis) or from a functional cause (such as intestinal pseudoobstruction), intestinal failure is a devastating disease process with profound morbidity and mortality. These patients require total parenteral nutrition (TPN) and are at risk of developing complications such as liver failure, catheter-related sepsis and loss of venous access. Intestinal transplantation, which has advanced markedly over the last 14 years, is now the accepted standard of care for patients failing TPN. Survival outcomes have improved significantly, infectious complications are better controlled, and new immunosuppressive therapies offer great hope for the future. In particular, the results of intestinal transplantation achieved with the motility disorders are equivalent to those experienced with other causes of intestinal failure. In themselves, the motility disorders present their own set of complicating factors, including determining the extent of the disease process (which may involve any part of the gastrointestinal tract), associated urological anomalies, and the type of organ transplantation required. Extensive workup and careful consideration is required before transplantation is undertaken. However, early referral is desirable once complications arise if these patients are to be offered optimal medical care before the chance of transplantation is lost.
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Affiliation(s)
- Geoffrey J Bond
- Thomas E. Starzl Transplantation Institute, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center Montefiore, 7-South, 3459 Fifth Avenue, Pittsburgh, PA 15213, USA.
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26
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Affiliation(s)
- Steven J Steiner
- Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
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27
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28
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Loinaz C, Mittal N, Kato T, Miller B, Rodriguez M, Tzakis A. Multivisceral transplantation for pediatric intestinal pseudo-obstruction: single center's experience of 16 cases. Transplant Proc 2004; 36:312-3. [PMID: 15050142 DOI: 10.1016/j.transproceed.2004.01.084] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Chronic intestinal pseudo-obstruction (CIPO) in children may be life-threatening due to the complications of parenteral nutrition (PN) or catheter-related sepsis. Multivisceral transplantation (MVTx) is a lifesaving option but limited experience is available. We report our experience with MVTx in pediatric CIPO patients. Sixteen children with CIPO underwent MVTx at median age of 4 years. Indications for MVTx were liver failure (n = 10), loss of venous access (n = 3), or sepsis (n = 3). Modified MVTx without the liver was performed in six patients. Induction immunosuppression included tacrolimus, steroid with adjunctive agent in period I (April 1996 to December 2000), namely, OKT3 (n = 1), mycophenolate mofetil (n = 4), or daclizumab (n = 2); and in period II (January 2001 to present), Campath 1H (n = 4) or daclizumab (n = 5). The grade of rejection was severe in 12.5% and mild to moderate in 87.5% of cases. Isolated rejection of the transplanted stomach or pancreas was not diagnosed during clinical course or on autopsy. Actuarial patient survival for 1 year/2 years for period, I and II were 57.1%/42.9% and 88.9%/77.8%. None of the long-term survivors is on PN and all tolerate enteral feedings. Pancreatic enzyme supplementation or insulin therapy is not needed in survivors. Gastric emptying was substantially affected in one case. Bladder function did not improve in those with urinary retention problems. MVTx for CIPO offers a lifesaving option with excellent function of the transplanted pancreas and stomach among survivors.
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Affiliation(s)
- C Loinaz
- Liver/GI Transplant Service, Miami, Florida, USA
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29
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Abstract
Intestinal failure (IF) can be defined as the reduction of functional gut mass below the minimal amount necessary for digestion and absorption adequate to satisfy the nutrient and fluid requirements for maintenance in adults or growth in children. In developed countries, IF mainly includes individuals with the congenital or early onset of conditions requiring protracted or indefinite parenteral nutrition (PN). Short bowel syndrome was the first commonly recognized cause of protracted IF. The normal physiologic process of intestinal adaptation after extensive resection usually allows for recovery of sufficient intestinal function within weeks to months. During this time, patients can be sustained on parenteral nutrition. Only a few children have permanent intestinal insufficiency and life-long dependency on PN. Non-transplant surgery including small bowel tapering and lengthening may allow weaning from PN in some cases. Hormonal therapy with recombinant human growth hormone has produced poor results while therapy with glucagon-like peptide-2 holds promise. Congenital diseases of enterocyte development such as microvillus inclusion disease or intestinal epithelial dysplasia cause permanent IF for which no curative medical treatment is currently available. Severe and extensive motility disorders such as total or subtotal intestinal aganglionosis (long segment Hirschsprung disease) or chronic intestinal pseudo-obstruction syndrome may also cause permanent IF. PN and home-PN remain are the mainstays of therapy regardless of the cause of IF. Some patients develop complications while receiving long-term PN for IF especially catheter related complications (thrombosis, sepsis) and liver disease. These patients may be candidates for intestinal transplantation. This review discusses the causes of irreversible IF and emphasizes the specific medico-surgical strategies for prevention and treatment of these conditions at several stages of IF.
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Affiliation(s)
- Olivier Goulet
- Département de Gastroentérologie, Hépatologie et Nutrition Pédiatriques, Hôpital Necker- Infants Malades and INSERM, Faculté de Necker, Paris, France.
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30
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Mittal NK, Tzakis AG, Kato T, Thompson JF. Current status of small bowel transplantation in children: update 2003. Pediatr Clin North Am 2003; 50:1419-33, ix. [PMID: 14710785 DOI: 10.1016/s0031-3955(03)00124-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
This article reviews the current indications for intestinal transplantation and advances in immunosuppression and postoperative care, which help to improve the outcome results of intestinal transplantation. Major current controversies and future trends are discussed briefly.
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Affiliation(s)
- Naveen K Mittal
- Department of Pediatrics, Division of Pediatric Gastroenterology and Nutrition, 1601 NW 12th Avenue (D-820), University of Miami, Miami, FL 33136, USA.
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31
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Abstract
Advances in immunosuppressive treatment as well as better monitoring and control of acute rejection have brought intestinal transplantation (ITx) into the realm of standard treatment for permanent intestinal failure. The results from the intestinal Transplant International Registry (www.intestinaltransplant.org) indicate that ITx is currently an acceptable clinical modality for selected patients with permanent intestinal failure. The goal of this short review is to deal with indications, clinical results and complications of ITx. Although it has been used in humans for the past two decades, very few data are available regarding graft function and its monitoring.
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Affiliation(s)
- Olivier Goulet
- Combined Programme of Intestinal Transplantation Hôspital Necker-Enfants Malades, Paris, France.
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32
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Lorenzo AJ, Twickler DM, Baker LA. Megacystis microcolon intestinal hypoperistalsis syndrome with bilateral duplicated systems. Urology 2003; 62:144. [PMID: 12837448 DOI: 10.1016/s0090-4295(03)00332-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 29-year-old multigravida woman presented for her second prenatal ultrasound evaluation at 30 weeks of gestation. The study showed a female fetus, bilateral duplicated systems with severe hydronephrosis in the upper pole moieties and a massively distended bladder. Initial interpretation suggested ectopic/obstructing bilateral ureteroceles. To evaluate these findings further, a prenatal magnetic resonance imaging scan was obtained, documenting the absence of ureteroceles. The presumptive diagnosis of megacystis microcolon intestinal hypoperistalsis syndrome was made. After birth, contrast enema confirmed the presence of microcolon. This appears to be the first reported case of megacystis microcolon intestinal hypoperistalsis syndrome with bilateral duplex systems evaluated with prenatal magnetic resonance imaging.
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Affiliation(s)
- Armando J Lorenzo
- Division of Pediatric Urology, University of Texas Southwestern Medical Center and Children's Hospital, Dallas, Texas, USA
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33
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Witters I, Theyskens C, van Hoestenberghe R, Sieprath P, Gyselaers W, Fryns JP. Prenatal diagnosis of non-obstructive megacystis as part of the megacystis-microcolon-intestinal hypoperistalsis syndrome with favourable postnatal outcome. Prenat Diagn 2001; 21:704-6. [PMID: 11536277 DOI: 10.1002/pd.114] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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34
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Kornberg A, Grube T, Wagner T, Homman M, Schotte U, Scheele J. Multivisceral transplantation for abdominal malignancy: indication, technique, and results in three patients. Transplant Proc 2001; 33:1558-9. [PMID: 11267420 DOI: 10.1016/s0041-1345(00)02593-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- A Kornberg
- Department of General and Visceral Surgery, Friedrich-Schiller-University of Jena, 07743, Jena, Germany
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Chamyan G, Debich-Spicer D, Opitz JM, Gilbert-Barness E. Megacystis-microcolon-intestinal hypoperistalsis syndrome and aganglionosis in trisomy 18. ACTA ACUST UNITED AC 2001. [DOI: 10.1002/ajmg.1469] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Iyer K, Kaufman S, Sudan D, Horslen S, Shaw B, Fox I, Langnas A. Long-term results of intestinal transplantation for pseudo-obstruction in children. J Pediatr Surg 2001; 36:174-7. [PMID: 11150460 DOI: 10.1053/jpsu.2001.20046] [Citation(s) in RCA: 34] [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
PURPOSE The aim of this study was to determine long-term results of intestinal transplantation in children with pseudo-obstruction, particularly when stomach and colon are not part of the allograft. METHODS The authors conducted a case-record review of all children who underwent transplantation at our center for a primary diagnosis of pseudo-obstruction. Supplementary information was obtained from outpatient charts, computerized database, and telephone survey of parents. RESULTS Six small bowel and 3 liver-small bowel transplants were carried out in 8 patients between 1993 and 1999. Median follow-up is 40 months (range, 13 to 73 months). Median age at transplantation was 2.7 years (range, 0.7 to 12.8 years). Median graft survival in this series is 15 months (range, 1 day to 71 months). Stomach and colon were excluded from all allografts. Two children died 5 and 368 days after transplant and 2 graft losses occurred in 1 patient. Two children had lymphoproliferative disease; both are alive with functioning grafts. Five survivors with functioning grafts receive full enteral feedings at home. Four of the 5 have had ileostomies closed, and 3 have normal bowel movements. CONCLUSIONS Intestinal transplantation without stomach or colon provides children with chronic intestinal pseudo-obstruction with a good quality of life. The underlying disease poses special challenges in management.
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Affiliation(s)
- K Iyer
- Organ Transplantation Program, University of Nebraska Medical Center, Omaha, NE 68198-3285, USA
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Abstract
The term 'intestinal failure' is now often used to describe gastrointestinal function insufficient to satisfy body nutrient and fluid requirements. The first recognized condition of intestinal failure was short bowel syndrome. Severe motility disorders such as chronic intestinal pseudo-obstruction syndrome in children as well as congenital intractable intestinal mucosa disorders are also forms of intestinal failure, because no curative treatment for these diseases is yet available. Parenteral nutrition and home parenteral nutrition remain the mainstay of therapy for intestinal failure, whether it is partial or total, provisional or permanent. However, some patients develop complications while receiving standard therapy for intestinal failure and are considered for intestinal transplantation. Indeed, recent advances in immunosuppressive treatment and the better monitoring and control of acute rejection have brought intestinal transplantation into the realm of standard treatment for intestinal failure. Although it has been used in humans for the past two decades, this procedure has had a slow learning curve. According to the current results, this challenging procedure may be performed in children or adults, only under certain conditions.
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Affiliation(s)
- O Goulet
- Intestinal Transplantation Group, Necker- Enfants Malades University Hospital, Paris, France.
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