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Intestine transplantation
ICD-9-CM46.97

Intestine transplantation, intestinal transplantation, or small bowel transplantation is the

short gut syndrome. While intestinal failure can oftentimes be treated with parenteral nutrition (PN), complications such as PN-associated liver disease may make The rarest type of organ transplantation performed, intestine transplantation is becoming increasingly prevalent as a therapeutic option due to improvements in immunosuppressive regiments, surgical technique, PN, and the clinical management of pre and post-transplant patients
.

History

Intestine transplantation dates back to

cyclosporine in 1972 triggered a revolution in the field of transplant medicine. Due to this discovery, in 1988, the first successful intestinal transplant was performed in Germany by E. Deltz, followed shortly by teams in France and Canada. Intestinal transplantation was no longer an experimental procedure, but rather a life-saving therapy. In 1990, a newer immunosuppressant drug, tacrolimus, appeared on the market as a superior alternative to cyclosporine. In the two decades since, intestine transplant efforts have improved tremendously in both volume and outcomes.[1][2]

Pre-transplant diagnoses and short-bowel syndrome

Failure of the small intestine would be life-threatening due to the inability to absorb

tumors, and volvulus.[9]

Alternative treatments

Regardless of the underlying condition, the loss of intestinal function does not necessarily necessitate a transplant. Several conditions, such as necrotizing enterocolitis or volvulus, may be adequately resolved by other surgical and nonsurgical treatments, especially if SBS never develops. An individual can obtain nutrients intravenously through PN, bypassing

enteral nutrition, but this is inadequate for many patients as it depends on the remaining intestine’s ability to adapt and increase its absorptive capacity.[3] Although more complicated and expensive to perform, any person may receive PN. Although PN can meet all energy, fluid, and nutrient needs and can be performed at home, quality of life can be significantly decreased. On average, PN takes 10 to 16 hours to administer but can take up to 24. Over this time frame, daily life can be significantly hindered as a consequence of attachment to the IV pump.[5][10] Over long periods of time, PN can lead to numerous health conditions, including severe dehydration, catheter-related infections, and liver disease.[2][11] PN-associated liver disease strikes up to 50% of patients within 5–7 years, correlated with a mortality rate of 2-50%.[11]

Another alternative treatment to transplant for patients with SBS is surgical bowel lengthening via either serial transverse enteroplasty (STEP) or the older longitudinal intestinal lengthening and tailoring (LILT) technique. Although both procedures contribute to an approximate 70% increase in length, STEP appears somewhat more favorable in terms of lower mortality and progression to transplant.[12] Nevertheless, a positive reception to either procedure may reduce the level of PN required, if not negate its required use altogether.[8][13]

Indications

There are four

Psychological preparations should be made for the transplant team and patient as well. Early referral requires trust between all parties involved in the operation to ensure that a rush to judgment does not lead to a premature transplant.[11][16]

Other

relative contraindication for intestine transplantation; desperate terminal patients may accept a transplant from a HIV-positive donor if they are willing to expose themselves to HIV.[14]

Transplant types

There are three major types of intestine transplants: an isolated intestinal

graft, a combined intestinal-liver graft, and a multivisceral graft in which other abdominal organs may be transplanted as well. In the most basic and common graft, an isolated intestinal graft, only sections of the jejunum and ileum are transplanted.[18] These are performed in the absence of liver failure. In the event of severe liver dysfunction due to PN, enzyme deficiencies, or other underlying factors, the liver may be transplanted along with the intestine. In a multivisceral graft, the stomach, duodenum, pancreas, and/or colon may be included in the graft. Multivisceral grafts are considered when the underlying condition significantly compromises other sections of the digestive system, such as intraabdominal tumors that have not yet metastasized, extensive venous thrombosis or arterial ischemia of the mesentery, and motility syndromes.[11][17]

Pre-operative period

organ rejection
by the body is all but certain.

Organ rejection is the unfortunate circumstance of the host

antibodies to various HLA antigens; in other words, how likely a patient is to acutely reject their new transplant. Therefore, it is essential that HLA and PRA statuses are tested for and demonstrate low immunoreactivity of the patient to the graft.[2][21][23] In some cases, a recipient may suffer from graft-versus-host disease, in which cells of the transplanted organ attack the recipient’s cells.[24]

To ensure proper histocompatibility, tissue quality, and safety from infection,

fungal infections, organ transplantation is not without extrasurgical risk.[2]

Waitlist and donation outcomes

A major challenge facing the intestinal transplant enterprise is meeting the need for transplantable intestines, particularly in the United States where the majority of intestinal transplants take place.

kg, cannot find a transplant due to the lack of size-matched donors.[8]

Despite these challenges, obtaining an intestine for transplant is rather probable in the United States. In

demographics of the American general population at the time aside from a below-average Asian cohort. ABO blood types also matched the general population, with 31% A, 14% B, 5% AB, and 50% O.[7] In 2004, the average waiting period to receive a transplant was 220 days,[21] with a median of 142 days in 2008.[7] The rate of waitlist additions has shifted from year to year; Gains increased until 2006 (with 317 added), but then decreased in 2012 (to 124 added).[25] In 2007, only 9% of patients on the U.S. waitlist died while waiting for a transplant.[7] Waitlist mortality peaked around 2002 and was highest for liver-intestine (pediatric) patients. Deaths among all pediatric groups awaiting intestine-liver transplants have decreased in the years leading up to 2014 whereas adult intestine-liver deaths have dropped less dramatically. The decrease in recent years is likely due to improved care of infants with intestinal failure and subsequently a decrease in referrals for transplant.[25] Although many improvements have been made in the States, outcomes everywhere still demonstrate much room for improvement. Worldwide, 25% of pediatric patients on the waitlist for an intestinal transplant die before they can receive one.[8]

Procurement protocol

Following matching of the organ, the complicated procurement of the small bowel can be performed by a team of abdominal transplant surgeons. Once a donor has been selected and approved for donation, several pretreatments may be initiated to destroy

lymphatic tissue, and have their bowel irrigated.[17]

Once donor preparation is accomplished, procurement can begin by utilizing the same standard techniques for all abdominal organ procurements. The team exposes the abdominal cavity and inserts two

vasculature in the ileum. The jejunum will be separated from the duodenum while preserving the vasculature of the jejunum, ileum, mesentery, and the pancreas. If healthy, the pancreas can oftentimes be retrieved as an additional isolated procurement. The intestinal allograft, when ready to be extracted, is attached by the mesenteric pedicle, where the vessels converge out of the intestinal system. This pedicle will be stapled closed, and can be separated from the body via a transverse cut to create a vascular cuff. The complete intestinal allograft can then be removed and wrapped in a surgical towel.[18]
The protocols for combined liver and multivisceral procurements are far more complicated and meticulous than isolated intestine alone.

Transplantation protocol

First, any abdominal

hepatic portal or superior mesenteric vein.[17] The graft is then reperfused with blood and any bleeding is stopped before the proximal and distal ends of the transplant bowel are connected to the original digestive tract. A loop ileostomy is then created as to provide easy access for future endoscopic observation and biopsies. A gastronomy or jejunostomy feeding tube may be placed before the abdominal wall is closed.[2]

When a liver is being transplanted in conjunction with the intestine, the recipient must first have their own liver removed. Following this, the aorta, cava, and portal veins of the donor and recipient are anastomosed. The graft is then flushed before the caval clamps are removed. The intestine is then reconstructed as in an isolated intestinal transplant, before being connected to the bile duct servicing the new liver.[17] Multivisceral transplants are especially difficult and susceptible to complications because all organs must survive a conjoined procurement, transport, and transplantation. All three of these measures are tailored to the individual needs of the recipient.[18] Preservation of the native spleen, pancreas, and duodenum during a multivisceral transplant can reduce the risk of additional complications related to these structures.[11]

Post-operative period

Following the procedure, the patient is actively monitored in an

mycophenolate mofetil), and the drugs cyclophosphamide and sirolimus are administered on an individual patient basis to further suppress the immune system.[11] The bioavailability of these drugs is dependent on intestinal surface area and transit time, and therefore the length of the allograft determines the immunosuppression regiment.[2] Intravenous administration of prostaglandin E1 is occasionally performed for the first 5 to 10 days following transplant to improve intestinal circulation and a potential dispensing of immunosuppressive effects[11]Cite error: The <ref> tag has too many names (see the help page). While suppression of the immune system may prevent immune attack on the new allograft, it may also prevent the immune system’s ability to keep certain gut microbial populations in line. Despite pre and post-decontamination of the transplant, recipients are at risk of local and systemic infection by both natural and external flora. The common symptom of graft dysfunction, whether due to infection, rejection, or some other condition, is diarrhea.[15]

Transplant outcomes and impact

Intestinal transplant outcomes have improved significantly in recent years. Despite mild incongruities in survival rate percentages between centers in

morbidity. Very young (<1 year) and very old (>60 years) patients receiving a transplant have pronounced rates of mortality.[14][15]
After 4 years, pediatric survival significantly worsens compared to adults .[14]

Several factors relating to superior patient and graft prognosis have proven to be statistically significant. Patients who have been admitted for transplant directly from home rather than the hospital, younger patients over one year of age, those receiving their first transplant, those receiving transplants at experienced transplant centers, and who receive antibody or sirolimus-based induction therapies have increased rates of survival.[9][15] Furthermore, underlying etiology,[26] the presence of comorbidity, the frequency of previous surgery, nutritional status, and the level of liver function have been found to affect patient-graft survival.[27] Patients with a pre-transplant diagnosis of volvulus were found to possess a lower risk of mortality.[26] As of 2008, the longest recorded surviving transplant survived for 18 years.[14] Between 1999 and 2008, 131 retransplant procedures were performed in the United States.[7]

The improvement to quality of life following an intestinal transplantation is significant. Of living patients 6 months after transplant, 70% are considered to have regained full intestinal function, 15% are at partial function, and 15% have had their grafts removed.

medical compliance, and the quality of relationships.[14][15][28]

Financial considerations

Receiving an organ transplant of any kind is a highly significant investment financially, but a successful, well-functioning transplant can be very cost-efficient relative to alternate therapies. Total charges to maintain PN at home can reach upwards of $150,000 a year, even though the actual cost of nutrition is typically only $18 to $22 a day.[5][14] This excludes the cost for additional home support, equipment, and the care of PN-related complications. The cost involved in undergoing intestinal transplantation, including the initial hospitalization for the transplant, can range from $150,000 to $400,000, and reoccurring hospitalizations are common up through the second year. Two to three years post-transplant, the financial cost of transplantation reaches parity with PN and is more cost-effective thereafter.[11][14]

References

  1. ^ Todo, S., Tzakis, A., Abu-Elmagd, K., Reyes, J., & Starzl, T. E. (1994). Current Status of Intestinal Transplantation. Advances in Surgery, 27, 295–316.
  2. ^ a b c d e f g h i Greenstein, S. M., Dunn, C.P., Friedmann, J.C., & Prowse, O. (2014) Intestinal Transplantation. Medscape. http://emedicine.medscape.com/article/1013245-overview
  3. ^ a b Duran, B. (2005). The effects of long-term total parenteral nutrition on gut mucosal immunity in children with short bowel syndrome: A systematic review. BMC Nursing, 4(2) doi:10.1186/1472-6955-4-2 Cite error: The named reference "Duran 2005" was defined multiple times with different content (see the help page).
  4. ^ Ghazi, L. J., Katz, J., Anand, B. S., Balasundaram, P., Coash, M. L., Nachimuthu, S., . . . Wu, G. Y. (2014). Crohn disease . Medscape, http://emedicine.medscape.com/article/172940
  5. ^ a b c d Buchman, A. L., Scolapio, J., & Fryer, J. (2003). AGA technical review on short bowel syndrome and intestinal transplantation. Gastroenterology, 124(4), 1111-1134.
  6. ^ Cagir, B. (2014). Short-Bowel Syndrome. Medscape. http://emedicine.medscape.com/article/193391-overview
  7. ^ a b c d e f g Mazariegos, G. V., Steffick, D. E., Horslen, S., Farmer, D., Fryer, J., Grant, D., ... & Magee, J. C. (2010). Intestine transplantation in the United States, 1999–2008. American Journal of Transplantation, 10(4p2), 1020-1034.
  8. ^ a b c d Mears, A., Lakhoo, K., & Millar, A. J. W. (2011). Chapter 71: Short bowel syndrome. In E. A. Ameh, S. W. Bickler, K. Lakhoo, B. C. Nwomeh & D. Poenaru (Eds.), Paediatric surgery: A comprehensive text for africa (pp. 424-428). Seattle, WA, USA: Global HELP Organization.
  9. ^ a b c d e Grant, D., Abu-Elmagd, K., Reyes, J., Tzakis, A., Langnas, A., Fishbein, T., ... & Intestine Transplant Registry. (2005). 2003 report of the intestine transplant registry: a new era has dawned. Annals of surgery, 241(4), 607.
  10. ^ Koletzko, B., Goulet, O., Hunt, J., Krohn, K., Shamir, R., & Parenteral Nutrition Guielines Working Group. (2005). 1. Guidelines on paediatric parenteral nutrition of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), supported by the European Society of Paediatric Research (ESPR). Journal of pediatric gastroenterology and nutrition, 41, S1-S4.
  11. ^ a b c d e f g h i j k Garg, M. Jones, R. M., Vaughan, R. B., Testro, A. G. (2011). Intestinal transplantation: Current status and future directions. Journal of Gastroenterology and Hepatology, 26, 1221-1228
  12. ^ Frongia, G., Kessler, M., Weih, S., Nickkholgh, A., Mehrabi, A., & Holland-Cunz, S. (2013). Comparison of LILT and STEP procedures in children with short bowel syndrome—A systematic review of the literature. Journal of pediatric surgery, 48(8), 1794-1805.
  13. ^ Bianchi, A. (1997). Longitudinal intestinal lengthening and tailoring: results in 20 children. Journal of the Royal Society of Medicine, 90(8), 429–432.
  14. ^ a b c d e f g h i j k Vianna, R. M., Mangus, R. S., & Tector, A. J. (2008). Current status of small bowel and multivisceral transplantation. Advances in surgery, 42, 129-150.
  15. ^ a b c d e f g Fishbein, T. M. (2009). Intestinal transplantation. New England Journal of Medicine, 361(10), 998-1008.
  16. ^ Fishbein, T. M., & Matsumoto, C. S. (2006). Intestinal replacement therapy: timing and indications for referral of patients to an intestinal rehabilitation and transplant program. Gastroenterology, 130(2), S147-S151.
  17. ^ a b c d e Troppmann, C. and Gruessner, R.W.G. Intestinal transplantation. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001. Available from: http://www.ncbi.nlm.nih.gov/books/NBK6902/
  18. ^ a b c d e Yersiz, H., Renz, J. F., Hisatake, G. M., Gordon, S., Saggi, B. H., Feduska Jr., N. J., . . . Farmer, D. G. (2003). Multivisceral and isolated intestinal procurement techniques. Liver Transplantation, 9(8), 881-886.
  19. ^ Gruessner, R. W., & Sharp, H. L. (1997). Living-related intestinal transplantation: first report of a standardized surgical technique. Transplantation, 64(11), 1605-1607.
  20. ^ Lock, M. M. (2002). Twice dead: Organ transplants and the reinvention of death (Vol. 1). Univ of California Press.
  21. ^ a b c Testa, G., Panaro, F., Schena, S., Holterman, M., Abcarian, H. Benedetti, E. (2004). Living Related Small Bowel Transplantation Donor Surgical Technique. Annals of Surgery, 240(5), 779-784
  22. ^ Kim, W. W., Gagner, M., Fukuyama, S., Hung, T. I., Biertho, L., Jacob, B. P., & Gentileschi, P. (2002). Laparoscopic harvesting of small bowel graft for small bowel transplantation. Surgical Endoscopy and Other Interventional Techniques, 16(12), 1786-1789.
  23. ^ a b Tietz, Norbert W. Clinical guide to laboratory tests. WB Saunders Co, 1995.
  24. ^ Pascher, A., Kohler, S., Neuhaus, P., & Pratschke, J. (2008). Present status and future perspectives of intestinal transplantation. Transplant International, 21(5), 401-414.
  25. ^ a b Khan, K. M., Desai, C. S., Mete, M., Desale, S., Girlanda, R., Hawksworth, J., et al. (2014). Developing trends in the intestinal transplant waitlist. American Journal of Transplantation : Official Journal of the American Society of Transplantation and the American Society of Transplant Surgeons,
  26. ^ a b Lao, O. B., Healey, P. J., Perkins, J. D., Horslen, S., Reyes, J. D., & Goldin, A. B. (2010). Outcomes in children after intestinal transplant. Pediatrics, 125(3), e550-e558.
  27. ^ Krawinkel, M. B., Scholz, D., Busch, A., Kohl, M., Wessel, L. M., & Zimmer, K. P. (2012). Chronic intestinal failure in children. Deutsches Ärzteblatt International, 109(22-23), 409.
  28. ^ Rovera, G. M., DiMartini, A., Schoen, R. E., Rakela, J., Abu-Elmagd, K., & Graham, T. O. (1998). Quality of life of patients after intestinal transplantation. Transplantation, 66(9), 1141-1145.

Category:Digestive system surgery Category:Gastroenterology Category:Organ transplantation


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