Adult intestinal failure and indications for transplantation:

Decision Making in Intestinal Transplantation

Intestinal transplantation is an accepted lifesaving option to treat appropriately selected patients with end-stage failure of the gastrointestinal tract. The evaluation of each candidate involves complex judgments. When to perform an isolated intestinal transplantation versus a combined transplantation with the liver and/or other organs often requires thoughtful considerations and an individualized approach. In addition, performing venous drainage of the isolated graft is potentially complex. We discuss the significant advances in surgical and medical decision making in the evaluation and management of patients with intestinal failure.

[Course and cares of intestinal transplant in immediate post-operative period]

OBJECTIVE

Describe the course and immediate post-operative care in patients with intestinal transplant.

MATERIAL AND METHODS

Descriptive, prospective study conducted in the Polyvalent Intensive Care Unit of a tertiary hospital for one year. Variables analyzed during the first 48 hours of the post-operative period: vital signs, O2 saturation, weaning time, diuresis, glycemia, catheters, drains, ileostomy, gastrostomy, TISS, NEMS, nursing cares, APACHE II and SAPS II on admission. Statistical analysis with SPSS 11.0.

RESULTS

Four patients, 50% women, mean age 42 +/- 8 years. Reason for intestinal transplant: 75% familial adenomatous polyposis with desmoid tumor and 25% mesenteric artery obstruction. They were administered alemtuzumab and tacrolimus. All the patients were carrier of central and arterial venous catheters, and Jackson Pratt abdominal drains (50% two, 50% three). Intubation time (median) 15 hours. APACHE II 10 +/- 6 y SAPS II 16 +/- 4. Means on first and second day of: systolic/diastolic blood pressure 132 +/- 23/73 +/- 11; 130 +/- 25/74 +/- 13 mmHg; glycemia 136 +/- 26/119 +/- 25 mg/dl; diuresis 95 +/- 34/125 +/- 30 cc/hour; TISS28 49 +/- 4/38 +/- 11 and NEMS 27 +/- 0/25 +/- 10, respectively. One re-operation due to hemorrhagic shock. Median study in Intensive Care Unit of 4 days.

CONCLUSIONS

1) They are hemodynamically stable patients with short weaning. They do not have many catheters, functioning ileostomy since the first day and TISS28 and NEMS in the middle of the range. 2) The most specific cares of the intestinal transplant are: surgical wound, drains, ileostomy, gastrostomy. 3) The need for intense immunosuppression implies strict isolation and nursing:patient ratio of 1:1.

Intestinal replacement therapy: timing and indications for referral of patients to an intestinal rehabilitation and transplant program

Current treatment options for patients suffering from intestinal insufficiency include all forms of intestinal replacement therapy (IRT). Parenteral nutrition has achieved extended success for the majority of patients requiring interval treatment, however, complications leading to failure of this treatment increases with the duration of therapy. There is currently no consensus as to the appropriate timing for transplantation of the intestine or the timing of referral for evaluation at a center experienced with this therapy. Certain patient characteristics warrant evaluation. Those patients with no jejunoileum who have guaranteed lifelong parenteral dependence, both adult and pediatric, should be immediately referred to a transplant center due to the high likelihood of the development of liver disease. Patients with metastatic infectious complications from catheter sepsis, patients with cholestasis seen intermittently with sepsis episodes, patients who are not successfully weaning and who demonstrate progressive thrombocytopenia, and patients with motility disorder experiencing deterioration should also warrant early referral to an intestinal rehabilitation and transplant program. The objective of evaluation is to maximize the opportunities for rehabilitation while not missing the critical window of opportunity for successful transplantation when needed. We favor an aggressive directed approach to rehabilitation, coupled with psychological preparation for both transplantations and other options. Early referral requires trust between the patient, referring physician, and the transplant team to assure that a rush to judgment will not lead to a premature transplant. The current wait list mortality is high, mandating early referral and listing with an approach aimed at maximizing both the success of gastrointestinal support, as well as of transplantation when necessary.