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Abreu P, Manzi J, Vianna R. Innovative surgical techniques in the intestine and multivisceral transplant. Curr Opin Organ Transplant 2024; 29:88-96. [PMID: 37902277 DOI: 10.1097/mot.0000000000001098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
PURPOSE OF REVIEW This timely review delves into the evolution of multivisceral transplantation (MVT) over the past six decades underscoring how advancements in surgical techniques and immunosuppression have driven transformation, to provide insight into the historical development of MVT, shedding light on its journey from experimentation to a valuable clinical approach. RECENT FINDINGS The review presents contemporary enhancements in surgical methods within the context of intestinal transplantation. The versatility of MVT is emphasized, accommodating diverse organ combinations and techniques. Both isolated intestinal transplantation (IIT) and MVT have seen expanded indications, driven by improved parenteral nutrition, transplantation outcomes, and surgical innovations. Surgical techniques are tailored based on graft type, with various approaches for isolated transplantation. Preservation strategies and ostomy techniques are also covered, along with graft assessment advancements involving donor-specific antibodies. SUMMARY This review's findings underscore the remarkable evolution of MVT from experimental origins to a comprehensive clinical practice. The progress in surgical techniques and immunosuppression has broadened the spectrum of patients who can benefit from intestinal transplant, including both IIT and MVT. The expansion of indications offers hope to patients with complex gastrointestinal disorders. The detection of donor-specific antibodies in graft assessment advances diagnostic accuracy, ultimately improving patient outcomes.
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Affiliation(s)
- Phillipe Abreu
- Department of Surgery, University of Miami, Jackson Memorial Hospital, Miami Transplant Institute, Florida, USA
| | - Joao Manzi
- Department of Surgery, University of Miami, Jackson Memorial Hospital, Miami Transplant Institute, Florida, USA
- University of Sao Paulo Medical School, University of Sao Paulo, Sao Paulo, Brazil
| | - Rodrigo Vianna
- Department of Surgery, University of Miami, Jackson Memorial Hospital, Miami Transplant Institute, Florida, USA
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Vianna R, Gaynor JJ, Selvaggi G, Farag A, Garcia J, Tekin A, Tabbara MM, Ciancio G. Liver Inclusion Appears to Be Protective Against Graft Loss-Due-to Chronic But Not Acute Rejection Following Intestinal Transplantation. Transpl Int 2023; 36:11568. [PMID: 37779512 PMCID: PMC10538304 DOI: 10.3389/ti.2023.11568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/28/2023] [Indexed: 10/03/2023]
Abstract
In intestinal transplantation, while other centers have shown that liver-including allografts have significantly more favorable graft survival and graft loss-due-to chronic rejection (CHR) rates, our center has consistently shown that modified multivisceral (MMV) and full multivisceral (MV) allografts have significantly more favorable acute cellular rejection (ACR) and severe ACR rates compared with isolated intestine (I) and liver-intestine (LI) allografts. In the attempt to resolve this apparent discrepancy, we performed stepwise Cox multivariable analyses of the hazard rates of developing graft loss-due-to acute rejection (AR) vs. CHR among 350 consecutive intestinal transplants at our center with long-term follow-up (median: 13.5 years post-transplant). Observed percentages developing graft loss-due-to AR and CHR were 14.3% (50/350) and 6.6% (23/350), respectively. Only one baseline variable was selected into the Cox model indicating a significantly lower hazard rate of developing graft loss-due-to AR: Transplant Type MMV or MV (p < 0.000001). Conversely, two baseline variables were selected into the Cox model indicating a significantly lower hazard rate of developing graft loss-due-to CHR: Received Donor Liver (LI or MV) (p = 0.002) and Received Induction (p = 0.007). In summary, while MMV/MV transplants (who receive extensive native lymphoid tissue removal) offered protection against graft loss-due-to AR, liver-containing grafts appeared to offer protection against graft loss-due-to CHR, supporting the results of other studies.
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Affiliation(s)
- Rodrigo Vianna
- Department of Surgery, Miami Transplant Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Jeffrey J. Gaynor
- Department of Surgery, Miami Transplant Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Gennaro Selvaggi
- Department of Surgery, Miami Transplant Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Ahmed Farag
- Department of Surgery, Miami Transplant Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
- Department of Surgery, Zagazig University School of Medicine, Zagazig, Egypt
| | - Jennifer Garcia
- Department of Pediatrics, Miami Transplant Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Akin Tekin
- Department of Surgery, Miami Transplant Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Marina M. Tabbara
- Department of Surgery, Miami Transplant Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Gaetano Ciancio
- Department of Surgery, Miami Transplant Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
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Weiner J, Llore N, Ormsby D, Fujiki M, Segovia MC, Obri M, Jafri SM, Liggett J, Kroemer AH, Matsumoto C, Moon J, Di Cocco P, Selvaggi G, Garcia J, Ganoza A, Khanna A, Mazariegos G, Wendel D, Reyes J. The First Collective Examination of Immunosuppressive Practices Among American Intestinal Transplant Centers. Transplant Direct 2023; 9:e1512. [PMID: 37636483 PMCID: PMC10455426 DOI: 10.1097/txd.0000000000001512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 05/23/2023] [Indexed: 08/29/2023] Open
Abstract
Background Unlike other solid organs, no standardized treatment algorithms exist for intestinal transplantation (ITx). We established a consortium of American ITx centers to evaluate current practices. Methods All American centers performing ITx during the past 3 y were invited to participate. As a consortium, we generated questions to evaluate and collect data from each institution. The data were compiled and analyzed. Results Ten centers participated, performing 211 ITx during the past 3 y (range, 3-46; mean 21.1). Induction regimens varied widely. Thymoglobulin was the most common, used in the plurality of patients (85/211; 40.3%), but there was no consensus regimen. Similarly, regimens for the treatment of acute cellular rejection, antibody-mediated rejection, and graft-versus-host disease varied significantly between centers. We also evaluated differences in maintenance immunosuppression protocols, desensitization regimens, mammalian target of rapamycin use, antimetabolite use, and posttransplantation surveillance practices. Maintenance tacrolimus levels, stoma presence, and scoping frequency were not associated with differences in rejection events. Definitive association between treatments and outcomes, including graft and patient survival, was not the intention of this initial collaboration and is prevented by the lack of patient-level data and the presence of confounders. However, we identified trends regarding rejection episodes after various induction strategies that require further investigation in our subsequent collaborations. Conclusions This initial collaboration reveals the extreme heterogeneity of practices among American ITx centers. Future collaboration will explore patient-level data, stratified by age and transplant type (isolated intestine versus multivisceral), to explore the association between treatment regimens and outcomes.
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Affiliation(s)
- Joshua Weiner
- Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, NY
| | - Nathaly Llore
- Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, NY
| | - Dylan Ormsby
- Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, NY
| | - Masato Fujiki
- Department of Surgery, Cleveland Clinic, Cleveland, OH
| | | | - Mark Obri
- Department of Medicine, Henry Ford Hospital, Detroit, MI
| | | | | | | | - Cal Matsumoto
- MedStar Georgetown Transplant Institute, Washington, DC
| | - Jang Moon
- Department of Surgery, Mount Sinai Medical Center, New York, NY
| | | | - Gennaro Selvaggi
- Miami Transplant Institute, University of Miami Jackson Memorial Hospital, Miami, FL
| | - Jennifer Garcia
- Miami Transplant Institute, University of Miami Jackson Memorial Hospital, Miami, FL
| | - Armando Ganoza
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Ajai Khanna
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - George Mazariegos
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Danielle Wendel
- Departments of Surgery and Pediatrics, University of Washington Medical Center/Seattle Children’s Hospital, Seattle, WA
| | - Jorge Reyes
- Departments of Surgery and Pediatrics, University of Washington Medical Center/Seattle Children’s Hospital, Seattle, WA
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Zorzetti N, Marino IR, Sorrenti S, Navarra GG, D'Andrea V, Lauro A. Small bowel transplant - novel indications and recent progress. Expert Rev Gastroenterol Hepatol 2023; 17:677-690. [PMID: 37264646 DOI: 10.1080/17474124.2023.2221433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 05/24/2023] [Indexed: 06/03/2023]
Abstract
INTRODUCTION Advances in the management of intestinal failure have led to a reduction in the number of intestinal transplants. The number of bowel transplants has been mainly stable even though a slight increase has been observed in the last 5 years. AREAS COVERED Standard indication includes patients with a reasonable life expectancy. Recent progress can be deduced by the increased number of intestine transplants in adults: this is due to the continuous improvement of 1-year graft survival worldwide (without differences in 3- and 5-year) associated with better abdominal wall closure techniques. This review aims to provide an update on new indications and changes in trends of pediatric and adult intestine transplantation. This analysis, which stretches through the past 5 years, is based on a collection of related manuscripts from PubMed. EXPERT COMMENTARY Intestinal transplants should be solely intended for a group of individuals for whom indications for transplantation are clear and both medical and surgical rehabilitations have failed. Nevertheless, many protocols developed over the years have not yet solved the key question represented by the over-immunosuppression. Novel indications and recent progress in the bowel transplant field, minimal yet consistent, represent a pathway to be followed.
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Affiliation(s)
- Noemi Zorzetti
- General Surgery, Ospedale Civile "A. Costa", Alto Reno Terme, Bologna, Italy
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Salvatore Sorrenti
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Vito D'Andrea
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Augusto Lauro
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
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Dogra H, Hind J. Innovations in Immunosuppression for Intestinal Transplantation. Front Nutr 2022; 9:869399. [PMID: 35782951 PMCID: PMC9241336 DOI: 10.3389/fnut.2022.869399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 05/03/2022] [Indexed: 11/13/2022] Open
Abstract
It has been 57 years since the first intestinal transplant. An increased incidence of graft rejection has been described compared to other solid organ transplants due to high immunogenicity of the bowel, which in health allows the balance between of dietary antigen with defense against pathogens. Expanding clinical experience, knowledge of gastrointestinal physiology and immunology have progress post-transplant immunosuppressive drug regimens. Current regimes aim to find the window between prevention of rejection and the risk of infection (the leading cause of death) and malignancy. The ultimate aim is to achieve graft tolerance. In this review we discuss advances in mucosal immunology and technologies informing the development of new anti-rejection strategies with the hope of improved survival in the next generation of transplant recipients.
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Merola J, Shamim A, Weiner J. Update on immunosuppressive strategies in intestinal transplantation. Curr Opin Organ Transplant 2022; 27:119-125. [PMID: 35232925 PMCID: PMC8915446 DOI: 10.1097/mot.0000000000000958] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The intestine is the most immunologically complex solid organ allograft with the greatest risk of both rejection and graft-versus-host disease (GVHD). High levels of immunosuppression are required, further increasing morbidity. Due to low volume of transplants and few centers with experience, there is paucity of evidence-based, standardized, and effective therapeutic regimens. We herein review the most recent data about immunosuppression, focusing on novel and emerging therapies. RECENT FINDINGS Recent data are moving the field toward increasing use of basilixumab and consideration of alemtuzumab for induction and inclusion of mammalian target of rapamycin inhibitors and antimetabolites for maintenance. For rejection, we highlight novel roles for tumor necrosis factor-α inhibition, α4β7 integrin inhibition, microbiome modulation, desensitization protocols, and tolerance induction strategies. We also highlight emerging novel therapies for GVHD, especially the promising role of Janus kinase inhibition. SUMMARY New insights into immune pathways associated with rejection and GVHD in intestinal allografts have led to an evolution of therapies from broad-based immunosuppression to more targeted strategies that hold promise for reducing morbidity from infection, rejection, and GVHD. These should be the focus of further study to facilitate their widespread use.
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Affiliation(s)
- Jonathan Merola
- Department of Surgery, Columbia University Irving Medical Center, New York, NY 10032
| | - Abrar Shamim
- Columbia University College of Dental Medicine, New York, NY 10032
- Columbia Center for Translational Immunology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY 10032
| | - Joshua Weiner
- Department of Surgery, Columbia University Irving Medical Center, New York, NY 10032
- Columbia Center for Translational Immunology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY 10032
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Crismale JF, Mahmoud D, Moon J, Fiel MI, Iyer K, Schiano TD. The role of endoscopy in the small intestinal transplant recipient: A review. Am J Transplant 2021; 21:1705-1712. [PMID: 33043624 DOI: 10.1111/ajt.16354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/10/2020] [Accepted: 09/30/2020] [Indexed: 01/25/2023]
Abstract
Intestinal transplantation (ITx) is the treatment of choice for patients with intestinal failure who have developed life-threatening complications related to long-term parenteral nutrition. Patients may also undergo ITx as part of a combined liver-intestine or multivisceral transplant for a variety of indications, most commonly intestinal failure-associated liver disease or porto-mesenteric thrombosis. Endoscopy plays a critical role in the posttransplant management of these patients, most commonly in the diagnosis and management of rejection, which occurs in up to 30-40% of patients within the first-year posttransplant. With a lack of noninvasive biomarkers to identify the presence of rejection, endoscopy and biopsy remain the gold standard for its diagnosis. Endoscopic evaluation of the graft is also important in the identification of other complications post-ITx, including posttransplant lymphoproliferative disorder, graft-versus-host disease, and enteric infections. Each patient's posttransplant anatomy may be slightly different, making endoscopy sometimes technically challenging and necessitating clear and frequent communication with the surgical team in order to help identify the highest yield approach. Herein, we review the most common pathologies found endoscopically in the post-ITx patient and describe some of the unique challenges the endoscopist faces when evaluating these complex patients.
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Affiliation(s)
- James F Crismale
- Recanati/Miller Transplantation Institute, The Mount Sinai Hospital, New York, New York, USA
| | - Dalia Mahmoud
- Atlantic Digestive Specialists, Wentworth-Douglass Hospital, Portsmouth, New Hampshire, USA
| | - Jang Moon
- Recanati/Miller Transplantation Institute, The Mount Sinai Hospital, New York, New York, USA
| | - M Isabel Fiel
- Department of Pathology and Laboratory Medicine, The Mount Sinai Hospital, New York, New York, USA
| | - Kishore Iyer
- Recanati/Miller Transplantation Institute, The Mount Sinai Hospital, New York, New York, USA
| | - Thomas D Schiano
- Recanati/Miller Transplantation Institute, The Mount Sinai Hospital, New York, New York, USA
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