Overview of intestinal and multivisceral transplantation
- Farrukh A Khan, MD, FACS
Farrukh A Khan, MD, FACS
- Clinical Professor of Surgery
- Drexel University College of Medicine
- Gennaro Selvaggi, MD
Gennaro Selvaggi, MD
- Associate Professor of Clinical Surgery
- University of Miami Miller School of Medicine
- Section Editor
- Robert S Brown, Jr, MD, MPH
Robert S Brown, Jr, MD, MPH
- Section Editor — Liver Transplantation
- Vice Chair, Transitions of Care, Department of Medicine
- Interim Chief, Division of Gastroenterology and Hepatology
- Weill Cornell Medical College
- Professor of Clinical Medicine, Columbia University College of Physicians & Surgeons
Intestinal transplantation (ITx) has evolved into an established therapeutic modality in the management of the patients with irreversible intestinal failure (IF). It is performed mainly in patients with short bowel syndrome, with multivisceral transplantation reserved for those patients who develop cholestatic liver disease from total parenteral nutrition. Primary indications for intestinal transplant include depletion of central venous access sites, multiple episodes of catheter related sepsis, electrolyte disturbance, dehydration, and progressive cholestatic liver failure. Additional indications for intestinal and multivisceral transplant include diffuse portomesenteric thrombosis, malignancies limited to the abdominal compartment, and congenital motility disorders of the intestine.
The number of patients who undergo ITx is much lower than for other forms of organ transplantation, and there are fewer centers that perform it. The Organ Procurement and Transplantation Network reported that in the United States between 1988 and 2014, a total of 2517 ITx were performed . The number of ITx was highest in 2007 (198 transplants), whereas in the past few years the total number of ITX performed each year has been stabilizing at approximately 100 to 120 transplantation cases per year. In 2014, 139 intestinal transplants were performed in the United States .
This topic review provides an overview of intestinal and multivisceral transplantation. The American Gastroenterological Association (AGA) guideline for short bowel syndrome and ITx , as well as other AGA guidelines, can be accessed through the AGA website.
Intestinal transplantation (ITx) has been performed in children with a variety of causes of short bowel syndrome (SBS) including congenital anomalies, necrotizing enterocolitis, intestinal atresia, mid-gut volvulus, gastroschisis, and motility disorders (figure 1). In adults, ITx has been performed mainly in those with SBS related to Crohn disease, mesenteric thrombosis, trauma, and desmoid tumors (figure 2) [3-5].
In both children and adults, ITx is usually considered in those who developed serious complications related to TPN, such as when:
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- Consensus criteria
- PRETRANSPLANT RECIPIENT EVALUATION
- WAIT LIST
- DONOR SELECTION/OPERATION
- General surgical principles
- - Isolated intestinal transplantation
- - Liver-intestinal transplantation
- - Multivisceral transplantation
- Bone marrow infusion
- Loss of domain/abdominal wall transplantation
- LIVING-RELATED TRANSPLANTATION
- ASSESSMENT OF INTESTINAL FUNCTION
- POSTOPERATIVE COMPLICATIONS
- Technical complications
- Infectious complications
- Post-transplant lymphoproliferative disease
- Graft-versus-host disease
- ACUTE REJECTION
- Clinical manifestations
- CHRONIC REJECTION AND GRAFT FAILURE
- Quality of life
- Karnofsky scores
- Graft and patient survival
- FUTURE DEVELOPMENTS
- SUMMARY AND RECOMMENDATIONS