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Garcia J, Oltean M, Rumbo C, Sharkey L, Kaufman SS, Ramos Boluda E, Gupte G, Martinez M, Moon J, Raghu V, Segovia MC, Sudan D, Talbotec C, Varkey J, Gondolesi GE, Mazariegos G, Venick R. Endoscopic Surveillance of the Intestinal Allograft: Recommendations From the Intestinal Rehabilitation and Transplant Association Working Group. Transplantation 2024; 108:827-835. [PMID: 37723639 DOI: 10.1097/tp.0000000000004785] [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: 09/20/2023]
Abstract
Intestinal transplant (ITx) rejection lacks a reliable noninvasive biomarker and rejection surveillance relies on serial endoscopies and mucosal biopsies followed by histologic assessment. Endoscopic biopsies are also essential for identifying other ITx-related complications such as infectious, allergic, and inflammatory graft enteritis as well as post-transplant lymphoproliferative disease or graft versus host disease. In spite of its central role in ITx, published guidelines on endoscopy and biopsy are lacking and significant variability between centers in terms of timing and technical performance exists. Therefore, an international expert group convened and discussed several aspects related to the surveillance endoscopy after ITx with the aim to summarize and standardize its practice. This article summarizes these considerations on endoscopic ITx monitoring and highlights practices of surveillance and for-cause endoscopy, biopsy techniques, pathologic evaluation, potential risks and complications, outsourcing, and less-invasive monitoring techniques.
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Affiliation(s)
- Jennifer Garcia
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, FL
| | - Mihai Oltean
- Sahlgrenska Intestinal Failure and Transplant Center, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Carolina Rumbo
- Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - Lisa Sharkey
- Department of Gastroenterology, Intestinal Failure and Intestinal/Multivisceral Transplant, Cambridge University Hospital, Cambridge, United Kingdom
| | | | | | - Girish Gupte
- Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Mercedes Martinez
- Center for Liver Disease and Abdominal Organ Transplantation, Columbia University Medical Center, New York, NY
| | - Jang Moon
- Recanati Miller Transplantation Institute, New York, NY
| | - Vikram Raghu
- Children's Hospital of Pittsburgh, Hillman Center for Pediatric Transplantation, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | | | - Cécile Talbotec
- Pediatric Gastroenterology-Hepatology-Nutrition, Hôpital Necker-Enfants Malades, Paris, France
| | - Jonas Varkey
- Sahlgrenska Intestinal Failure and Transplant Center, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - George Mazariegos
- Children's Hospital of Pittsburgh, Hillman Center for Pediatric Transplantation, University of Pittsburgh Medical Center, Pittsburgh, PA
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Hussan E, Kroemer A, Elsabbagh AM, Khan KM, Yazigi NA, Ekong UD, Subramanian S, Ghobrial SS, Guerra JF, Fishbein TM, Matsumoto CS, Kaufman SS. Idiopathic Ileal Ulceration After Intestinal Transplantation. Transplant Direct 2023; 9:e1529. [PMID: 37899780 PMCID: PMC10602531 DOI: 10.1097/txd.0000000000001529] [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: 05/11/2023] [Revised: 06/09/2023] [Accepted: 06/19/2023] [Indexed: 10/31/2023] Open
Abstract
Background Idiopathic ileal ulceration after intestinal transplantation (ITx) has been discussed infrequently and has an uncertain natural history and relation to graft rejection. Herein, we review our experience with this pathology. Methods We retrospectively reviewed 225 ITx in 217 patients with minimum 1 y graft survival. Routine graft endoscopy was conducted up to twice weekly within the first 90 d after ITx, gradually decreasing to once yearly. Risks for ulceration over time were evaluated using Cox regression. Results Of 93 (41%) patients with ulcers, 50 were found within 90 d after ITx mostly via ileoscopy; delayed healing after biopsy appeared causal in the majority. Of the remaining 43 patients with ulcers found >90 d after ITx, 36 were after ileostomy closure. Multivariable modeling demonstrated within 90-d ulcer associations with increasing patient age (hazard ratio [HR], 1.027; P < 0.001) and loop ileostomy (versus Santulli ileostomy; HR, 0.271; P < 0.001). For ulcers appearing after ileostomy closure, their sole association was with absence of graft colon (HR, 7.232; P < 0.001). For ulcers requiring extended anti-microbial and anti-inflammatory therapy, associations included de novo donor-specific antibodies (HR, 3.222; P < 0.007) and nucleotide oligomerization domain mutations (HR, 2.772; P < 0.016). Whole-cohort post-ITx ulceration was not associated with either graft rejection (P = 0.161) or graft failure (P = 0.410). Conclusions Idiopathic ulceration after ITx is relatively common but has little independent influence on outcome; risks include ileostomy construction, colon-free ITx, immunologic mutation, and donor sensitization.
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Affiliation(s)
- Elsadig Hussan
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
| | - Alexander Kroemer
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Ahmed M. Elsabbagh
- Gastroenterology Surgical Center, Department of Surgery, Mansoura University, Mansoura, Egypt
| | - Khalid M. Khan
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Nada A. Yazigi
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Udeme D. Ekong
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Sukanya Subramanian
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | | | - Juan-Francisco Guerra
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Thomas M. Fishbein
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Cal S. Matsumoto
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Stuart S. Kaufman
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
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Schairer J, Fahad H. Endoscopy in the Surgically Altered Bowel. Gastrointest Endosc Clin N Am 2022; 32:777-799. [PMID: 36202516 DOI: 10.1016/j.giec.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Improved utilization of surgical interventions to improve patient outcomes has led to an increased need to endoscopically evaluate and treat the bowel after surgery. The best outcomes are attained when the endoscopist coordinates with the surgeon, and in some cases the pathologist or radiologist to plan the procedure. Understanding the anatomy and pathology anticipated can allow planning for sedation, bowel cleanse and equipment needed. Surgically altered anatomy can create challenges that with planning can be overcome. This article will review how to prepare and navigate several of the most commonly encountered surgical interventions.
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Affiliation(s)
- Jason Schairer
- Division of Gastroenterology, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48202, USA.
| | - Hamna Fahad
- Division of Gastroenterology, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48202, USA
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Endoscopic visualization of graft status in patients with pancreas transplantation. Surg Endosc 2022; 36:4057-4066. [PMID: 34782963 DOI: 10.1007/s00464-021-08727-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 08/30/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Enteric drainage into the recipient duodenum in pancreas transplantation (PT) can identify the graft duodenum by endoscopy. This study aimed to identify the characteristic endoscopic findings associated with graft failure or acute rejection in patients with PT. METHODS We reviewed the medical records of patients who underwent PT with duodenoduodenostomy (DD) between January 2015 and August 2019. During this period, there were 44 PTs with DD in 42 patients; 122 endoscopies were performed and analyzed. RESULTS Overall, pancreatic graft survival was 82% at a mean follow-up of 27 months (range 6-55 months). There were 8 graft failures and 10 acute rejections. In all 8 graft failures, a deep ulcer covered with fibrinous exudates of the graft duodenum was confirmed on endoscopy. Diffuse erythema inside the graft duodenum was observed in 8 of 10 acute rejections. The factors associated with acute rejection were elevated serum lipase level (OR 8.5, p = 0.02) and diffuse erythema inside the graft duodenum on endoscopy (OR 20.5, p < 0.01) in multivariate analysis. CONCLUSIONS In PT with DD patients, graft failure can be visualized by endoscopy, and diffuse erythema inside the graft duodenum may be a finding of acute rejection.
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Wichmann D, Nadalin S, Schweizer U, Solaß W, Steidle C, Stüker D, Lange J, Werner CR, Königsrainer A, Quante M. Evaluating the diagnostic value of zoom endoscopic surveillance compared to routine biopsy after intestinal transplantation. Dig Liver Dis 2022; 54:385-390. [PMID: 35090824 DOI: 10.1016/j.dld.2021.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/28/2021] [Accepted: 12/29/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND After intestinal transplantation, close allograft monitoring especially during the early postoperative period is crucial since the intestine is a highly immunogenic organ. Current protocols are based on endoscopic and histologic examination with the latter one being linked to the risk of bleeding and perforation. AIMS Evaluation of the diagnostic value of endoscopy utilizing magnification to predict acute cellular rejection compared to routine allograft biopsies. METHODS Fourteen patients underwent the protocol with longitudinal zoom endoscopic and histological graft monitoring during the first year after transplantation. The intestinal mucosa was analyzed during endoscopy utilizing the SASAKI score while a minimum of two biopsies were taken during each examination. A new graduation of severity for acute cellular rejection based on the findings of the SASAKI score is established. RESULTS Endoscopic findings of 385 examinations and more than 1000 intestinal allograft biopsies were analyzed. A total of 7 acute cellular rejection episodes in 6/14 patients occurred. Allograft endoscopy was able to diagnose ACR with a sensitivity of 76% and a specificity of 82%. CONCLUSIONS Our results will be critical for refining protocols for allograft monitoring after intestinal transplantation thus paving the way towards less invasive measures.
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Affiliation(s)
- Dörte Wichmann
- Department of General, Visceral and Transplantation Surgery, University Hospital Tübingen, 72076, Tübingen, Germany.
| | - Silvio Nadalin
- Department of General, Visceral and Transplantation Surgery, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Ulrich Schweizer
- Department of General, Visceral and Transplantation Surgery, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Wiebke Solaß
- Department of Pathology, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Christoph Steidle
- Department of General, Visceral and Transplantation Surgery, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Dietmar Stüker
- Department of General, Visceral and Transplantation Surgery, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Jessica Lange
- Department of Surgery, Filderklinik 70794, Filderstadt-Bonlanden, Germany
| | - Christoph R Werner
- Department of Internal Medicine I, Gastroenterology, Infectiology, Gastrointestinal Oncology, Hepatology and Geriatrics, University Hospital Tübingen, 72076 Tübingen, Germany
| | - Alfred Königsrainer
- Department of General, Visceral and Transplantation Surgery, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Markus Quante
- Department of General, Visceral and Transplantation Surgery, University Hospital Tübingen, 72076, Tübingen, Germany
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6
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Jelly ET, Kwun J, Schmitz R, Farris AB, Steelman ZA, Sudan DL, Knechtle SJ, Wax A. Optical coherence tomography of small intestine allograft biopsies using a handheld surgical probe. JOURNAL OF BIOMEDICAL OPTICS 2021; 26:JBO-210108R. [PMID: 34561973 PMCID: PMC8461564 DOI: 10.1117/1.jbo.26.9.096008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 09/08/2021] [Indexed: 06/13/2023]
Abstract
SIGNIFICANCE The current gold standard for monitoring small intestinal transplant (IT) rejection is endoscopic visual assessment and biopsy of suspicious lesions; however, these lesions are only superficially visualized by endoscopy. Invasive biopsies provide a coarse sampling of tissue health without depicting the true presence and extent of any pathology. Optical coherence tomography (OCT) presents a potential alternative approach with significant advantages over traditional white-light endoscopy. AIM The aim of our investigation was to evaluate OCT performance in distinguishing clinically relevant morphological features associated with IT graft failure. APPROACH OCT was applied to evaluate the small bowel tissues of two rhesus macaques that had undergone IT of the ileum. The traditional assessment from routine histological observation was compared with OCT captured using a handheld surgical probe during the days post-transplant and subsequently was compared with histophaology. RESULTS The reported OCT system was capable of identifying major biological landmarks in healthy intestinal tissue. Following IT, one nonhuman primate (NHP) model suffered a severe graft ischemia, and the second NHP graft failed due to acute cellular rejection. OCT images show visual evidence of correspondence with histological signs of IT rejection. CONCLUSIONS Results suggest that OCT imaging has significant potential to reveal morphological changes associated with IT rejection and to improve patient outcomes overall.
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Affiliation(s)
- Evan T. Jelly
- Duke University, Department of Biomedical Engineering, Durham, North Carolina, United States
| | - Jean Kwun
- Duke University Medical Center, Duke Transplant Center, Department of Surgery, Durham, United States
| | - Robin Schmitz
- Duke University Medical Center, Duke Transplant Center, Department of Surgery, Durham, United States
| | - Alton B. Farris
- Emory University, Department of Pathology, Atlanta, Georgia, United States
| | - Zachary A. Steelman
- Duke University, Department of Biomedical Engineering, Durham, North Carolina, United States
| | - Debra L. Sudan
- Duke University Medical Center, Duke Transplant Center, Department of Surgery, Durham, United States
| | - Stuart J. Knechtle
- Duke University Medical Center, Duke Transplant Center, Department of Surgery, Durham, United States
| | - Adam Wax
- Duke University, Department of Biomedical Engineering, Durham, North Carolina, United States
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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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8
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Varkey J. Graft assessment for acute rejection after intestinal transplantation: current status and future perspective. Scand J Gastroenterol 2021; 56:13-19. [PMID: 33202155 DOI: 10.1080/00365521.2020.1847318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Intestinal transplantation has since its inception evolved as a lifesaving treatment option for patients with irreversible intestinal failure who can no longer be sustained on parenteral nutrition. Improvement in short-term survival after transplantation has also justified the expansion of treatment indications. Unfortunately, success is somewhat limited by a plateau observed in long-term survival. The reason for this sub-optimal long-term result experienced in this cohort may in part be attributed to the intestinal graft with the lymphoid content it carries inflicting the host with multiple complications where acute cellular rejection is one of the most common causes for graft loss. Graft monitoring is for this reason of paramount importance and detection of rejection at an early stage essential to enable early instigation of treatment and successful reversal of the pathology. Due to the challenges in diagnosing acute rejection with a noninvasive marker we are still limited to a surveillance protocol using endoscopy and biopsies for the diagnosis of rejection. The purpose of our paper is to review the adequacy of different methods in monitoring the graft for acute rejection using biomarkers, endoscopy and imaging. In conclusion, the evidence base continues to support the use of histology for the diagnosis of acute rejection. The role of biomarkers are still debatable, although markers such as calprotectin might be beneficial in excluding an ongoing process.
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Affiliation(s)
- Jonas Varkey
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Sahlgrenska Intestinal Failure and Transplant Centre, Gothenburg, Sweden
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9
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Chung CS, Tsai CC, Chen KC, Lin CK, Lee TH, Tsai HW, Chen Y. Surveillance of Rejection After Intestinal Transplantation Using an Image Enhanced Endoscopy "VENCH" Scoring System. Transplant Proc 2020; 53:364-370. [PMID: 33309060 DOI: 10.1016/j.transproceed.2020.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 10/01/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Graft rejection after intestinal transplantation remains challenging. We aimed to use endoscopy for rejection prediction. MATERIALS AND METHODS Patients ≥7 years old who underwent intestinal transplantation between November 2016 and September 2019 were prospectively enrolled. Magnifying endoscopy under narrow-band imaging was performed through ileostomy. Endoscopic findings were reported as five components (each graded from 0-2): "V" (villi appearance), "E" (erythema), "N" (capillary network), "C" (crypt widening), and "H" (heterogeneity). The correlation between histological severity and endoscopic score was analyzed. RESULTS Ninety-nine endoscopic biopsies from three female and one male patient were analyzed. The mean ± SD age was of 41.25±13.77 (range 29-58) years. Three short bowel syndrome patients after multiple intestinal resections and one with chronic intestinal pseudo-obstruction were indicated for intestinal transplantation. Sensitivity, specificity, and accuracy of V, E, N, C, and H scores for predicting rejection were 97.4%, 45.9%, 65.7%; 94.7%, 70.5%, 79.8%; 97.4%, 52.5%, 69.7%; 94.7%, 54.1%, 69.7%; and 97.4%, 62.3%, 75.8%, respectively. Pearson's correlation coefficients between total and individual V, E, N, C, H scores and histological rejection were 0.79, 0.64, 0.70, 0.71, 0.73, and 0.66, respectively (P < .001). To predict mild and moderate/severe rejection, total scores more than 4 and 6 had the sensitivity/specificity of 87.50%/57.38% and 96.67%/85.25%, respectively (area under the ROC 0.791 and 0.987). CONCLUSION Endoscopic VENCH scoring is promising for predicting rejection after IT. More studies are warranted to validate such results. (ClinicalTrials.gov number, NCT03616548.).
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Affiliation(s)
- Chen-Shuan Chung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan; Taiwan Association for the Study of Small Intestinal Diseases (TASSID), Taoyuan City, Taiwan; College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chien-Chen Tsai
- Department of Anatomical Pathology, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Kuan-Chih Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan; Taiwan Association for the Study of Small Intestinal Diseases (TASSID), Taoyuan City, Taiwan
| | - Cheng-Kuan Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Tzong-Hsi Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan; Taiwan Association for the Study of Small Intestinal Diseases (TASSID), Taoyuan City, Taiwan
| | - Huang-Wen Tsai
- Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Yun Chen
- Taiwan Association for the Study of Small Intestinal Diseases (TASSID), Taoyuan City, Taiwan; Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan; Department of Chemical Engineering and Materials Science, Yuan Ze University, Taoyuan City, Taiwan.
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10
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Moon JI, Schiano TD, Iyer KR. Routine surveillance endoscopy and biopsy after isolated intestinal transplantation—Revisiting the gold standard. Clin Transplant 2019; 33:e13684. [DOI: 10.1111/ctr.13684] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 06/12/2019] [Accepted: 07/29/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Jang I. Moon
- Recanati Miller Transplantation Institute Icahn School of Medicine at Mount Sinai New York New York
| | - Thomas D. Schiano
- Recanati Miller Transplantation Institute Icahn School of Medicine at Mount Sinai New York New York
| | - Kishore R. Iyer
- Recanati Miller Transplantation Institute Icahn School of Medicine at Mount Sinai New York New York
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11
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Parfenov AI, Sabelnikova EA, Kuzmina TN. [Short bowel syndrome]. TERAPEVT ARKH 2019; 89:144-149. [PMID: 29488474 DOI: 10.17116/terarkh20178912144-149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The paper gives information on the classification, pathogenesis, and clinical manifestations of short bowel syndrome following after intestinal resection. It discusses the treatment and rehabilitation of patients with this condition.
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Affiliation(s)
- A I Parfenov
- A.S. Loginov Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
| | - E A Sabelnikova
- A.S. Loginov Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
| | - T N Kuzmina
- A.S. Loginov Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
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12
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Hakim B, Myers DT, Williams TR, Nagai S, Bonnett J. Intestinal transplants: review of normal imaging appearance and complications. Br J Radiol 2018; 91:20180173. [PMID: 29770706 DOI: 10.1259/bjr.20180173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Intestinal transplant (IT) is one of the least common forms of organ transplant but is increasing both in volume of cases and number of centers performing intestinal transplants, with the busiest centers in North America and Europe. IT can be performed in isolation or as part of a multivisceral transplant (MVT). Intestinal failure either in the form of short gut syndrome or functional bowel problems is the primary indication for IT. The normal post-surgical anatomy can be variable due to both recipient anatomy in regard to amount of residual bowel and status of native vasculature as well as whether the transplant is isolated or part of a multivisceral transplant. Complications of isolated IT and IT as part of an MVT include complications shared with other types of organ transplants such as infection, rejection, post-transplant lymphoproliferative disorder and graft versus host disease. Mechanical bowel complications of the graft include bowel obstruction, stricture, leak, perforation and enterocutaneous fistula. Lastly, vascular complications of both the venous and arterial anastomoses including stricture and pseudoaneurysm occur.
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Affiliation(s)
- Bashir Hakim
- 1 Department of Radiology, Henry Ford Hospital , Detroit, MI , USA
| | - Daniel T Myers
- 1 Department of Radiology, Henry Ford Hospital , Detroit, MI , USA
| | - Todd R Williams
- 1 Department of Radiology, Henry Ford Hospital , Detroit, MI , USA
| | - Shunji Nagai
- 2 Department of Transplant Surgery, Henry Ford Hospital , Detroit, MI , USA
| | - John Bonnett
- 1 Department of Radiology, Henry Ford Hospital , Detroit, MI , USA
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13
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Varkey J, Stotzer PO, Simrén M, Herlenius G, Oltean M. The endoscopic surveillance of the transplanted small intestine: a single center experience and a proposal for a grading score. Scand J Gastroenterol 2018; 53:134-139. [PMID: 29233031 DOI: 10.1080/00365521.2017.1411523] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Microscopic examination of endoscopic biopsies forms the basis of acute cellular rejection (ACR) monitoring after intestinal transplantation (ITx). The endoscopy findings during acute rejection (AR) are known but a grading system for its severity is lacking. We designed and implemented a five-stage grading score based on acknowledged endoscopic features of AR, to allow a faster preliminary diagnosis of AR and intra- and interpatient comparisons. METHODS Two investigators reviewed and graded the endoscopy reports after 28 ITx using a novel score and correlated the results with pathology findings. RESULTS We reviewed 512 ileoscopies: 370 examinations (74%) were normal (G0), 59 had mild alterations (erythema, edematous villi-G1) and 36 showed moderate changes (erosions, blunted villi-G2); 17 ileoscopies revealed advanced changes (ulcerations, villus loss-G3). In 18 endoscopies the changes were severe (mucosal loss-G4). Inter-reviewer agreement was very good (kappa = 0.81). Biopsies from 86 endoscopy sessions (17%) indicated ACR with 63 cases having moderate or severe ACR. For mild ACR the sensitivity of the score was 29% and the specificity was 86% whereas the positive (PPV) and negative predictive values (NPVs) were 14% and 93% respectively. During advanced ACR the sensitivity and specificity were 92% and 86%, respectively whereas the PPV and NPV were 49% and 98% respectively. CONCLUSIONS Endoscopy alone has a limited ability to reliably diagnose intestinal ACR. We suggest a novel grading score summarizing ACR findings and allowing comparisons between intestinal graft endoscopies.
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Affiliation(s)
- Jonas Varkey
- a Department of Internal Medicine & Clinical Nutrition, Institute of Medicine , Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - Per-Ove Stotzer
- a Department of Internal Medicine & Clinical Nutrition, Institute of Medicine , Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - Magnus Simrén
- a Department of Internal Medicine & Clinical Nutrition, Institute of Medicine , Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden.,b Center for Functional Gastrointestinal and Motility Disorders , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
| | - Gustaf Herlenius
- c Transplant Institute , Sahlgrenska University Hospital , Gothenburg , Sweden.,d Department of Surgery, Institute for Clinical Sciences , Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - Mihai Oltean
- c Transplant Institute , Sahlgrenska University Hospital , Gothenburg , Sweden.,d Department of Surgery, Institute for Clinical Sciences , Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
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Apostolov R, Asadi K, Lokan J, Kam N, Testro A. Mycophenolate mofetil toxicity mimicking acute cellular rejection in a small intestinal transplant. World J Transplant 2017; 7:98-102. [PMID: 28280702 PMCID: PMC5324035 DOI: 10.5500/wjt.v7.i1.98] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 12/21/2016] [Accepted: 01/14/2017] [Indexed: 02/05/2023] Open
Abstract
Mycophenolate mofetil (MMF) is an important medication used for maintenance immunosuppression in solid organ transplants. A common gastrointestinal (GI) side effect of MMF is enterocolitis, which has been associated with multiple histological features. There is little data in the literature describing the histological effects of MMF in small intestinal transplant (SIT) recipients. We present a case of MMF toxicity in a SIT recipient, with histological changes in the donor ileum mimicking persistent acute cellular rejection (ACR). Concurrent biopsies of the patient’s native colon showed similar changes to those from the donor small bowel, suggesting a non-graft specific process, raising suspicion for MMF toxicity. The MMF was discontinued and complete resolution of these changes occurred over three weeks. MMF toxicity should therefore be considered as a differential diagnosis for ACR and graft-versus-host disease in SITs.
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Bharadwaj S, Tandon P, Gohel TD, Brown J, Steiger E, Kirby DF, Khanna A, Abu-Elmagd K. Current status of intestinal and multivisceral transplantation. Gastroenterol Rep (Oxf) 2017; 5:20-28. [PMID: 28130374 PMCID: PMC5444259 DOI: 10.1093/gastro/gow045] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Clinical-nutritional autonomy is the ultimate goal of patients with intestinal failure (IF). Traditionally, patients with IF have been relegated to lifelong parenteral nutrition (PN) once surgical and medical rehabilitation attempts at intestinal adaptation have failed. Over the past two decades, however, outcome improvements in intestinal transplantation have added another dimension to the therapeutic armamentarium in the field of gut rehabilitation. This has become possible through relentless efforts in the standardization of surgical techniques, advancements in immunosuppressive therapies and induction protocols and improvement in postoperative patient care. Four types of intestinal transplants include isolated small bowel transplant, liver-small bowel transplant, multivisceral transplant and modified multivisceral transplant. Current guidelines restrict intestinal transplantation to patients who have had significant complications from PN including liver failure and repeated infections. From an experimental stage to the currently established therapeutic modality for patients with advanced IF, outcome improvements have also been possible due to the introduction of tacrolimus in the early 1990s. Studies have shown that intestinal transplant is cost-effective within 1-3 years of graft survival compared with PN. Improved survival and quality of life as well as resumption of an oral diet should enable intestinal transplantation to be an important option for patients with IF in addition to continued rehabilitation. Future research should focus on detecting biomarkers of early rejection, enhanced immunosuppression protocols, improved postoperative care and early referral to transplant centers.
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Affiliation(s)
- Shishira Bharadwaj
- Center for Gut Rehabilitation and Transplantation, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Parul Tandon
- Center for Gut Rehabilitation and Transplantation, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Tushar D Gohel
- Center for Gut Rehabilitation and Transplantation, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jill Brown
- Center for Gut Rehabilitation and Transplantation, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ezra Steiger
- Center for Gut Rehabilitation and Transplantation, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Donald F Kirby
- Center for Gut Rehabilitation and Transplantation, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ajai Khanna
- Center for Gut Rehabilitation and Transplantation, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Kareem Abu-Elmagd
- Center for Gut Rehabilitation and Transplantation, the Cleveland Clinic Foundation, Cleveland, OH, USA
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16
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Initial Experience of Video Capsule Endoscopy After Intestinal Transplantation. Transplant Direct 2016; 2:e119. [PMID: 27990484 PMCID: PMC5142358 DOI: 10.1097/txd.0000000000000628] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 09/06/2016] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Intestinal transplantation is a procedure which inflicts immunological and infectious complications that affect the transplanted graft, posing both diagnostic and therapeutic challenges. Video capsule endoscopy (VCE) offers easy access to the entire small intestine and presents itself as an interesting option. However, at present, no studies evaluating the usefulness of video capsule endoscopies in this setting have been published. Our aim was to evaluate the usefulness of VCE in detecting complications that arise after intestinal transplantation. METHODS We included 7 adult patients with either isolated intestine (n = 1) or multivisceral grafts (n = 6). These patients underwent 12 VCE between 2004 and 2015 at the Sahlgrenska University Hospital. The median age was 42 (21-67) years (4 women/3 men). VCE was used in clinical situations where the conventional diagnostic methods failed to provide answers to the clinical question. RESULTS Indications for the procedure were: suspicion of rejection (n = 4 examinations), gastrointestinal dysmotility (n = 4 examinations), high stomal output (n = 2 examinations), suspicion of lymphoproliferative disease in the transplanted graft (n = 1 examination), and clinical surveillance (n = 1 examination). The median time after transplantation for performing an examination was 740 (26-3059) days. VCE was useful in 83% of the examinations and the results influenced the planned management. The overall agreement between VCE findings and biopsies was moderate (κ = 0.54, P = 0.05) but increased when comparing the presence of inflammation/rejection (κ = 0.79, P < 0.001). CONCLUSIONS VCE is a promising diagnostic method after intestinal transplantation. However, larger studies are needed to evaluate its potential risks and gains.
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Huard G, Schiano T, Fiel MI, Ward SC, Moon J, Iyer K. Comparative incidence of rejection occurring in small intestinal and colonic mucosal biopsies of patients undergoing intestinal transplantation. Histopathology 2016; 69:600-6. [DOI: 10.1111/his.12982] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 04/06/2016] [Indexed: 12/01/2022]
Affiliation(s)
- Geneviève Huard
- Intestinal Transplant Program; Recanati Miller Transplant Institute; The Mount Sinai Hospital; New York NY USA
- Department of Medicine; Liver Unit; Centre Hospitalier de l'Université de Montréal; Montreal QC Canada
| | - Thomas Schiano
- Intestinal Transplant Program; Recanati Miller Transplant Institute; The Mount Sinai Hospital; New York NY USA
| | - Marie I Fiel
- Department of Pathology; Division of GI Pathology; The Mount Sinai Hospital; New York NY USA
| | - Stephen C Ward
- Department of Pathology; Division of GI Pathology; The Mount Sinai Hospital; New York NY USA
| | - Jang Moon
- Intestinal Transplant Program; Recanati Miller Transplant Institute; The Mount Sinai Hospital; New York NY USA
| | - Kishore Iyer
- Intestinal Transplant Program; Recanati Miller Transplant Institute; The Mount Sinai Hospital; New York NY USA
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Abstract
OBJECTIVES Biopsies remain the criterion standard in the diagnosis of intestinal transplant (ITx) rejection, and gastrointestinal endoscopy plays a pivotal role in patient management. Herein, we describe a single-center 23-year endoscopic experience in pediatric ITx recipients. METHODS A retrospective review of endoscopy and pathology reports of all ITx recipients <18 years old transplanted between 1991 and 2013 was performed with the aim of describing the procedural indications, findings, and complications. RESULTS A total of 1770 endoscopic procedures within 1014 sessions were performed. A combination of esophagogastroduodenoscopy and ileoscopy was the most common procedure (36%). Increased stool output (35%) and surveillance endoscopy (32%) were the most common indications. A total of 162 episodes of biopsy-proven rejection were diagnosed. The first episode of rejection occurred at a median of 1 month after ITx. Of histology-proven rejections, 45% had normal-appearing endoscopies. The rate of procedural complications, including but not limited to bleeding and perforation, was 1.8%. CONCLUSIONS Endoscopy with biopsy plays a significant role in the care of ITx recipients. Multiple procedures are required for graft surveillance, diagnosis of rejection, subsequent treatment, and follow-up of therapy. The gross endoscopic appearance, particularly in mild to moderate acute cellular rejection, does not correlate well with histology. Complex anatomy, complication rates that are higher than patients with non-ITx pediatric endoscopy, and timely histologic interpretation by experienced pathologists are reasons that these procedures should be performed at centers accustomed to caring for ITx recipients. The field would benefit from the development of a noninvasive biomarker to reliably and efficiently detect rejection.
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Zambernardi A, Chiodetti A, Meier D, Cabanne A, Nachman F, Solar H, Rumbo C, Gondolesi GE, Rumbo M. Immunosuppressive therapies after intestinal transplant modulate the expression of Th1 signature genes during acute cellular rejection. Implications in the search for rejection biomarkers. Clin Transplant 2014; 28:1365-71. [DOI: 10.1111/ctr.12464] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2014] [Indexed: 12/24/2022]
Affiliation(s)
- Agustina Zambernardi
- Laboratorio de Investigaciones del Sistema Inmune (LISIN); Facultad de Cs. Exactas; Universidad Nacional de La Plata; La Plata Argentina
- Instituto de Transplante Multiorgánico; Fundación Favaloro; Buenos Aires Argentina
| | - Ana Chiodetti
- Laboratorio de Investigaciones del Sistema Inmune (LISIN); Facultad de Cs. Exactas; Universidad Nacional de La Plata; La Plata Argentina
| | - Dominik Meier
- Instituto de Transplante Multiorgánico; Fundación Favaloro; Buenos Aires Argentina
| | - Ana Cabanne
- Instituto de Transplante Multiorgánico; Fundación Favaloro; Buenos Aires Argentina
| | - Fabio Nachman
- Instituto de Transplante Multiorgánico; Fundación Favaloro; Buenos Aires Argentina
| | - Héctor Solar
- Instituto de Transplante Multiorgánico; Fundación Favaloro; Buenos Aires Argentina
| | - Carolina Rumbo
- Instituto de Transplante Multiorgánico; Fundación Favaloro; Buenos Aires Argentina
| | - Gabriel E. Gondolesi
- Instituto de Transplante Multiorgánico; Fundación Favaloro; Buenos Aires Argentina
| | - Martin Rumbo
- Laboratorio de Investigaciones del Sistema Inmune (LISIN); Facultad de Cs. Exactas; Universidad Nacional de La Plata; La Plata Argentina
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Hilmi IA, Planinsic RM, Nicolau-Raducu R, Damian D, Al-Khafaji A, Sakai T, Abu-Elmagd K. Isolated small bowel transplantation outcomes and the impact of immunosuppressants: Experience of a single transplant center. World J Transplant 2013; 3:127-133. [PMID: 24392317 PMCID: PMC3879522 DOI: 10.5500/wjt.v3.i4.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 07/19/2013] [Indexed: 02/05/2023] Open
Abstract
AIM: To investigate patient and graft outcomes in isolated small bowel transplant (SBTx) recipients and immunosuppressant induction agent impact on outcomes.
METHODS: A retrospective review of the perioperative data of patients who underwent SBTx transplant during an 8-year period was conducted. The intraoperative data were: patient demographics, etiology of short gut syndrome, hemodynamic parameters, coagulation profiles, intraoperative fluid and blood products transfused, and development of post-reperfusion. The postoperative data were: hospital/intensive care unit stays, duration of mechanical ventilation, postoperative incidence of acute kidney injury, and 1-year patient and graft outcomes. The effects of the three immunosuppressant induction agents (Zenapax, Thymoglobulin, Campath) on patient and graft outcomes were reviewed.
RESULTS: During the 8-year period there were 77 patients; 1-year patient and graft survival were 95% and 86% respectively. Sixteen patients received Zenapax, 22 received Thymoglobulin, and 39 received Campath without effects on patient or graft survival (P = 0.90, P =
0.14, respectively). The use of different immune induction agents did not affect the incidence of rejection and infection during the first 90 postoperative days (P = 0.072, P = 0.29, respectively). The Zenapax group received more intraoperative fluid and blood products and were coagulopathic at the end of surgery. Zenapax and Thymoglobulin significantly increased serum creatinine at 48 h (P = 0.023) and 1 wk (P = 0.001) post-transplant, but none developed renal failure or required dialysis at the end of the first year.
CONCLUSION: One-year patient and graft survival were 95% and 86%, respectively. The use of different immunosuppressant induction agents may affect the intraoperative course and short-term postoperative morbidities, but not 1-year patient and graft outcomes.
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Franks I. Transplantation: Graft surveillance in small bowel transplantation. Nat Rev Gastroenterol Hepatol 2012; 9:618. [PMID: 23007478 DOI: 10.1038/nrgastro.2012.192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
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