Intestinal and multivisceral transplantation in patients with chronic intestinal failure

Emerging role of carbon monoxide in intestinal transplantation

Intestinal transplantation has become an established therapeutic option that provides improved quality of life to patients with end-stage intestinal failure when total parenteral nutrition fails. Whereas this challenging life-saving intervention has shown exceptional growth over the past decade, illustrating the evolution of this complex and technical procedure from its preclinical origin in the mid-20th century to become a routine clinical practice today with several recent innovations, its success is hampered by multiple hurdles including technical challenges such as surgical manipulation during intestinal graft procurement, graft preservation and reperfusion damage, resulting in poor graft quality, graft rejection, post-operative infectious complications, and ultimately negatively impacting long-term recipient survival. Therefore, strategies to improve current intestinal transplantation protocol may have a significant impact on post-transplant outcomes. Carbon monoxide (CO), previously considered solely as a toxic gas, has recently been shown to be a physiological signaling molecule at low physiological concentrations with therapeutic potentials that could overcome some of the challenges in intestinal transplantation. This review discusses recent knowledge about CO in intestinal transplantation, the underlying molecular mechanisms of protection during intestinal graft procurement, preservation, transplantation and post-transplant periods. A section of the review also discusses clinical translation of CO and its challenges in the field of solid organ transplantation.

Fragmented management of long-term parenteral support for adult intestinal failure in Finland

Objectives: Parenteral support (PS) is the first-line therapy for intestinal failure (IF). Optimal patient outcomes require experienced multidisciplinary teams adhering to structured protocols. As practices to provide long-term PS for adult IF patients in Finland are unknown, this cross-sectional nationwide study aimed to evaluate current management of PS for adult IF across the country. Materials and methods: An internet-based survey was emailed to all Finnish hospitals and hospital-at-home services with the potential to provide PS for adult IF. The survey included 20 items addressing the provision of long-term PS for adult IF patients (aged ≥18 years). Data were analysed using descriptive statistics. Results: Overall, 52 (47%) of the 111 identified units responded. Of responding units, 38 (73%) had at some point provided long-term (≥120 days) PS for adult IF, and 23 (44%) had done so during the preceding year. Only three units currently managed ≥3 adult patients. Most (65%) of the respondents worked in a hospital and were either physicians (38%) or dietitians (39%). Only 65% of respondents reported that their unit had an assigned physician responsible for PS provision, and 28% reported that a team was responsible for long-term PS. Only 26% of respondents reported having a written protocol to guide PS management. Conclusions: Health care providers with very limited experience and a fragmented approach manage most Finnish adult IF patients. Evidence-based protocols and multidisciplinary teams are scarce. The care for adult IF patients on long-term PS needs to be improved in Finland.