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:To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- http://optn.transplant.hrsa.gov/latestData/rptData.asp (Accessed on March 14, 2014).
- American Gastroenterological Association. American Gastroenterological Association medical position statement: short bowel syndrome and intestinal transplantation. Gastroenterology 2003; 124:1105.
- Todo S, Reyes J, Furukawa H, et al. Outcome analysis of 71 clinical intestinal transplantations. Ann Surg 1995; 222:270.
- Reyes JD. Intestinal transplantation. Semin Pediatr Surg 2006; 15:228.
- Todo S, Tzakis A, Abu-Elmagd K, et al. Abdominal multivisceral transplantation. Transplantation 1995; 59:234.
- Selvaggi G, Gyamfi A, Kato T, et al. Analysis of vascular access in intestinal transplant recipients using the Miami classification from the VIIIth International Small Bowel Transplant Symposium. Transplantation 2005; 79:1639.
- Chungfat N, Dixler I, Cohran V, et al. Impact of parenteral nutrition-associated liver disease on intestinal transplant waitlist dynamics. J Am Coll Surg 2007; 205:755.
- Buchman AL, Scolapio J, Fryer J. AGA technical review on short bowel syndrome and intestinal transplantation. Gastroenterology 2003; 124:1111.
- Kaufman SS, Atkinson JB, Bianchi A, et al. Indications for pediatric intestinal transplantation: a position paper of the American Society of Transplantation. Pediatr Transplant 2001; 5:80.
- Pironi L, Forbes A, Joly F, et al. Survival of patients identified as candidates for intestinal transplantation: a 3-year prospective follow-up. Gastroenterology 2008; 135:61.
- Abu-Elmagd K, Bond G. Gut failure and abdominal visceral transplantation. Proc Nutr Soc 2003; 62:727.
- Abu-Elmagd KM. Intestinal transplantation for short bowel syndrome and gastrointestinal failure: current consensus, rewarding outcomes, and practical guidelines. Gastroenterology 2006; 130:S132.
- Iyer KR, Iverson AK, DeVoll-Zabrocki A, et al. Pediatric intestinal transplantation--review of current practice. Nutr Clin Pract 2002; 17:350.
- Bowyer BA, Fleming CR, Ludwig J, et al. Does long-term home parenteral nutrition in adult patients cause chronic liver disease? JPEN J Parenter Enteral Nutr 1985; 9:11.
- Fiel MI, Sauter B, Wu HS, et al. Regression of hepatic fibrosis after intestinal transplantation in total parenteral nutrition liver disease. Clin Gastroenterol Hepatol 2008; 6:926.
- optn.transplant.hrsa.gov/ar2009 (Accessed on March 18, 2014).
- Smith JM, Skeans MA, Horslen SP, et al. OPTN/SRTR 2013 Annual Data Report: intestine. Am J Transplant 2015; 15 Suppl 2:1.
- Reyes J, Mazariegos GV, Bond GM, et al. Pediatric intestinal transplantation: historical notes, principles and controversies. Pediatr Transplant 2002; 6:193.
- Khan FA, Tzakis AG. Intestinal and Multivisceral Transplantation. In: Transplantation, Ginns, Cosmi, Morris (Eds), Blackwell Science, 1999. p.422.
- Niv Y, Mor E, Tzakis AG. Small bowel transplantation--a clinical review. Am J Gastroenterol 1999; 94:3126.
- Kato T, Selvaggi G, Gaynor JJ, et al. Inclusion of donor colon and ileocecal valve in intestinal transplantation. Transplantation 2008; 86:293.
- Vianna R, Fridell JA, Mangus R, et al. Safe inclusion of the entire pancreas as a component of the multivisceral graft. Transplantation 2008; 86:114.
- Kamada N, Davies HS, Roser B. Reversal of transplantation immunity by liver grafting. Nature 1981; 292:840.
- Wu G, Cruz RJ. Liver inclusion improves outcomes of intestinal retransplantation in adults. [Corrected]. Transplantation 2015; 99:1265.
- Kato T, Tzakis AG, Selvaggi G, et al. Intestinal and multivisceral transplantation in children. Ann Surg 2006; 243:756.
- Abu-Elmagd K, Reyes J, Bond G, et al. Clinical intestinal transplantation: a decade of experience at a single center. Ann Surg 2001; 234:404.
- Levi DM, Tzakis AG, Kato T, et al. Transplantation of the abdominal wall. Lancet 2003; 361:2173.
- Deltz E, Schroeder P, Gebhardt H, et al. Successful clinical bowel transplantation: report of a case. Clin Transplant 1989; 3:89.
- Benedetti E, Holterman M, Asolati M, et al. Living related segmental bowel transplantation: from experimental to standardized procedure. Ann Surg 2006; 244:694.
- www.intestinaltransplant.org (Accessed on February 15, 2008).
- www.optn.org/latestData/rptData.asp (Accessed on February 15, 2008).
- Mueller AR, Pascher A, Platz KP, et al. Immunosuppression following intestinal transplantation. Transplant Proc 2004; 36:325.
- Reyes J, Mazariegos GV, Abu-Elmagd K, et al. Intestinal transplantation under tacrolimus monotherapy after perioperative lymphoid depletion with rabbit anti-thymocyte globulin (thymoglobulin). Am J Transplant 2005; 5:1430.
- Kadry Z, Furukawa H, Abu-Elmagd K, et al. Use of the D-xylose absorption test in monitoring intestinal allografts. Transplant Proc 1994; 26:1645.
- Abu-Elmagd KM, Kosmach-Park B, Costa G, et al. Long-term survival, nutritional autonomy, and quality of life after intestinal and multivisceral transplantation. Ann Surg 2012; 256:494.
- Flynn B, Park BK, Bond G, et al. Immunosuppressant strategies for intestinal transplantation: a review of a tolerogenic regimen. Prog Transplant 2005; 15:60.
- Haghighi KS, Sharif K, Mirza DF, et al. Surgical complications of intestinal transplantation. Transplantation 2006; 82(1 Suppl 2):466.
- Wu G, Selvaggi G, Nishida S, et al. Graft-versus-host disease after intestinal and multivisceral transplantation. Transplantation 2011; 91:219.
- Mazariegos GV, Abu-Elmagd K, Jaffe R, et al. Graft versus host disease in intestinal transplantation. Am J Transplant 2004; 4:1459.
- Wu T, Abu-Elmagd K, Bond G, et al. A schema for histologic grading of small intestine allograft acute rejection. Transplantation 2003; 75:1241.
- Selvaggi G, Gaynor JJ, Moon J, et al. Analysis of acute cellular rejection episodes in recipients of primary intestinal transplantation: a single center, 11-year experience. Am J Transplant 2007; 7:1249.
- Tzakis AG, Thompson JF. Current status of diagnosis of small bowel rejection. Pediatr Transplant 1998; 2:87.
- Kato T, O'Brien CB, Nishida S, et al. The first case report of the use of a zoom videoendoscope for the evaluation of small bowel graft mucosa in a human after intestinal transplantation. Gastrointest Endosc 1999; 50:257.
- Kato T, Gaynor JJ, Nishida S, et al. Zoom endoscopic monitoring of small bowel allograft rejection. Surg Endosc 2006; 20:773.
- Lauro A, Altimari A, Di Simone M, et al. Acute cellular rejection monitoring after intestinal transplant: utility of serologic markers and zoom videoendoscopy as support of conventional biopsy and clinical findings. Transplant Proc 2008; 40:1575.
- Abu-Elmagd K, Reyes J, Bond G, et al. A novel immunomodulatory strategy for clinical intestinal transplantation: Ex-vivo irradiation with adjunct bone marrow infusion. Program and abstracts of Transplant 2001: The Joint American Transplant Meeting; May 11-16, 2001; Chicago Illinois. Concurrent session 47: Small Bowel Transplantation; Abstract 912.
- Parizhskaya M, Redondo C, Demetris A, et al. Chronic rejection of small bowel grafts: pediatric and adult study of risk factors and morphologic progression. Pediatr Dev Pathol 2003; 6:240.
- Abu-Elmagd KM, Reyes J, Fung JJ, et al. Evolution of clinical intestinal transplantation: improved outcome and cost effectiveness. Transplant Proc 1999; 31:582.
- Sudan D. Cost and quality of life after intestinal transplantation. Gastroenterology 2006; 130:S158.
- Sudan D, Horslen S, Botha J, et al. Quality of life after pediatric intestinal transplantation: the perception of pediatric recipients and their parents. Am J Transplant 2004; 4:407.
- O'Keefe SJ, Emerling M, Koritsky D, et al. Nutrition and quality of life following small intestinal transplantation. Am J Gastroenterol 2007; 102:1093.
- Abu-Elmagd KM, Costa G, Bond GJ, et al. Five hundred intestinal and multivisceral transplantations at a single center: major advances with new challenges. Ann Surg 2009; 250:567.
- 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