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Ceulemans LJ, Dubois A, Clarysse M, Canovai E, Venick R, Mazariegos G, Vanuytsel T, Hibi T, Avitzur Y, Hind J, Horslen S, Gondolesi G, Benedetti E, Gruessner R, Pirenne J. Outcome After Intestinal Transplantation From Living Versus Deceased Donors: A Propensity-matched Cohort Analysis of the International Intestinal Transplant Registry. Ann Surg 2023; 278:807-814. [PMID: 37497671 PMCID: PMC10549910 DOI: 10.1097/sla.0000000000006045] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVE To describe the worldwide experience with living donation (LD) in intestinal transplantation (ITx) and compare short-term and long-term outcomes to a propensity-matched cohort of deceased donors. BACKGROUND ITx is a rare life-saving procedure for patients with complicated intestinal failure (IF). Living donation (LD)-ITx has been performed with success, but no direct comparison with deceased donation (DD) has been performed. The Intestinal Transplant Registry (ITR) was created in 1985 by the Intestinal Transplant Association to capture the worldwide activity and promote center's collaborations. METHODS Based on the ITR, 4156 ITx were performed between January 1987 and April 2019, of which 76 (1.8%) were LD, including 5 combined liver-ITx, 7 ITx-colon, and 64 isolated ITx. They were matched with 186 DD-ITx for recipient age/sex, weight, region, IF-cause, retransplant, pretransplant status, ABO compatibility, immunosuppression, and transplant date. Primary endpoints were acute rejection and 1-/5-year patient/graft survival. RESULTS Most LDs were performed in North America (61%), followed by Asia (29%). The mean recipient age was: 22 years; body mass index: 19kg/m²; and female/male ratio: 1/1.4. Volvulus (N=17) and ischemia (N=17) were the most frequent IF-causes. Fifty-two percent of patients were at home at the time of transplant. One-/5-year patient survival for LD and DD was 74.2/49.8% versus 80.3/48.1%, respectively ( P =0.826). One-/5-year graft survival was 60.3/40.6% versus 69.2/36.1%, respectively ( P =0.956). Acute rejection was diagnosed in 47% of LD versus 51% of DD ( P =0.723). CONCLUSION Worldwide, LD-ITx has been rarely performed. This retrospective matched ITR analysis revealed no difference in rejection and in patient/graft survival between LD and DD-ITx.
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Affiliation(s)
- Laurens J. Ceulemans
- Leuven Intestinal Failure and Transplantation (LIFT), University Hospitals Leuven, Leuven, Belgium
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Antoine Dubois
- Leuven Intestinal Failure and Transplantation (LIFT), University Hospitals Leuven, Leuven, Belgium
- Abdominal Transplant Surgery & Transplant Coordination, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Experimental Surgery and Transplantation (CHEX), University Hospital Saint-Luc, Brussels, Belgium
| | - Mathias Clarysse
- Leuven Intestinal Failure and Transplantation (LIFT), University Hospitals Leuven, Leuven, Belgium
- Abdominal Transplant Surgery & Transplant Coordination, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Emilio Canovai
- Leuven Intestinal Failure and Transplantation (LIFT), University Hospitals Leuven, Leuven, Belgium
- Abdominal Transplant Surgery & Transplant Coordination, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Robert Venick
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Mattel Children’s Hospital at UCLA Medical Center, Los Angeles, CA
| | - George Mazariegos
- Hillman Center for Pediatric Transplantation, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States of America
| | - Tim Vanuytsel
- Leuven Intestinal Failure and Transplantation (LIFT), University Hospitals Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Taizo Hibi
- Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Yaron Avitzur
- Department Gastroenterology, Hepatology, and Nutrition, SickKids Hospital, Toronto, Canada
| | - Jonathan Hind
- Department of Paediatric Liver, Gastrointestinal and Nutrition Centre, King’s College Hospital, London
| | - Simon Horslen
- Department of Gastroenterology, Hepatology, and Nutrition, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Gabriel Gondolesi
- Department of General Surgery, Nutritional Support Unit, Liver, Pancreas, and Intestinal Transplant Unit, Favaloro Foundation University Hospital, Buenos Aires, Argentina
| | - Enrico Benedetti
- Department of Surgery, University of Illinois Hospital, Chicago, IL
| | - Rainer Gruessner
- Department of Surgery, SUNY Downstate Health Sciences University, New York City, NY
| | - Jacques Pirenne
- Leuven Intestinal Failure and Transplantation (LIFT), University Hospitals Leuven, Leuven, Belgium
- Abdominal Transplant Surgery & Transplant Coordination, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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Intestinal Transplantation from Living Donors. LIVING DONOR ADVOCACY 2014. [PMCID: PMC7122154 DOI: 10.1007/978-1-4614-9143-9_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Intestinal transplantation (ITx) represents the physiologic alternative to total parenteral nutrition (TPN) for patients suffering from life-threatening complications of irreversible intestinal failure. The number of transplants performed worldwide has been increasing for several years until recently. ITx has recently become a valid therapeutic option with a graft survival rate between 80 % and 90 % at 1 year, in experienced centers. These results have been achieved due to a combination of several factors: better understanding of the pathophysiology of intestinal graft, improved immunosuppression techniques, more efficient strategies for the monitoring of the bowel graft, as well as control of infectious complications and posttransplant lymphoproliferative disease (PTLD). In fact, this procedure is associated with a relatively high rate of complications, such as infections, acute rejection, graft versus host disease (GVHD), and PTLD, if compared to the transplantation of other organs. These complications may be, at least in part, the consequence of the peculiarity of this graft, which contains gut-associated lymphoid tissue and potentially pathogenic enteric flora. Furthermore, in these patients, the existing disease and the relative malnutrition could predispose them to infectious complications. Additionally, other factors associated with the procedure, such as laparotomy, preservation injury, abnormal motility, and lymphatic disruption, could all be implicated in the development of complications.
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Setty S, Wu SJ, Bogard A, Chejfec G, Carroll R, Benedetti E, John E, Setty A. Application of the paraboloidal model to assess mucosal changes following segmental intestinal transplantation in children. Transplant Proc 2011; 43:1823-30. [PMID: 21693285 DOI: 10.1016/j.transproceed.2011.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2010] [Accepted: 03/01/2011] [Indexed: 10/18/2022]
Abstract
Segmental living related small intestinal transplantation (LRSITx) is a therapeutic option for conditions that present with short gut syndromes. Recovery of small intestinal mucosa after transplantation is critical to function. We examined the posttransplant mucosal changes to understand the absorptive capabilities of transplanted small intestine. The study of human subjects is constrained by limited biopsy material; therefore, we developed a technique of villus area measurement by extrapolation from two-dimensional surgical biopsy images. Using a detailed model of the villus as the gold standard, two simpler models (cylindrical and paraboloid) were tested. Comparisons with the accurate measurement revealed that the cylinder model does not compare well in early posttransplant biopsies. The paraboloid function developed in this article worked very well under all conditions. The simplicity of the paraboloid model and its robustness made high-quality estimates of the absorptive surface area from abundant data relatively easy. The remodeling expected in the initial stages of growth was also captured by this model. Time-dependent villus growth curves were obtained for transplanted bowel. Serial biopsies showed an initial "reconstruction" dip around 2 weeks after transplant, followed by continuous growth of villus surface area. An eventual plateau resulted at an average of 6 months after transplant. This growth of villi was shown to parallel the improved absorption of electrolytes, amino acids, and water.
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Affiliation(s)
- S Setty
- Department of Pathology, University of Illinois Medical Center at Chicago, Illinois, USA
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Misra MV, Bhattacharya K, Nompleggi DJ, Uknis ME, Rastellini C, Cicalese L. Magnification Endoscopy as a Reliable Tool for the Early Diagnosis of Rejection in Living Related Small Bowel Transplants: A Case Report. Transplant Proc 2006; 38:1738-9. [PMID: 16908267 DOI: 10.1016/j.transproceed.2006.05.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The purpose was to determine whether magnification endoscopy (ME) accurately diagnosed rejection in living related small bowel transplants (LRSBTx) during initial morphological adaptation of segmental intestinal grafts. The small bowel recipient was a 44-year-old woman with short gut syndrome following multiple bowel surgeries for familial adenomatous polyposis. ME was enhanced by chromoendoscopy staining. Bowel mucosa was washed with acetic acid and stained with methylene blue for optimal visualization of mucosal villi and to improve the diagnostic yield of biopsies. The recipient underwent surveillance ME with biopsy 16 times through the ileostomy in the first 9 months following transplantation. The recipient developed diarrhea in the postoperative course, which led to the suspicion of rejection. ME findings of patchy villus blunting were consistent with biopsy samples that showed mild acute cellular rejection. Episodes of rejection were treated with high-dose immunosuppressants and steroids. Reversal of rejection was monitored by follow-up ME, which showed increased length of villi and normalization of morphology. Biopsy confirmed these findings. The first endoscopy, at 5 days posttransplant, showed no evidence of intestinal ischemia. LRSBTx involves early morphological adaptation of the recipient small bowel mucosa, characterized by an increased length of villi. ME is a reliable technique to follow adaptation and detect early rejection. The superior imaging of small bowel mucosa created by ME chromoendoscopy enables early diagnosis and delivery of more prompt antirejection therapy to prevent progression of rejection. ME also confirmed that segmental LRSBTx caused minimal ischemic injury to the recipient.
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Affiliation(s)
- M V Misra
- Division of Organ Transplantation, Department of Surgery, University of Massachusetts Medical School-UMass/Memorial Healthcare, 55 Lake Avenue North, Worcester, MA 01655, USA
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Weale AR, Edwards AG, Bailey M, Lear PA. Intestinal adaptation after massive intestinal resection. Postgrad Med J 2005. [PMID: 15749794 DOI: 10.1136/pgmj.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Patients with short bowel syndrome require long term parenteral nutrition support. However, after massive intestinal resection the intestine undergoes adaptation and nutritional autonomy may be obtained. Given that the complications of parenteral nutrition may be life threatening or result in treatment failure and the need for intestinal transplantation, a more attractive option is to wean patients off nutrition support by optimising the adaptive process. The article examines the evidence that after extensive small bowel resection adaptation occurs in humans and focuses on the factors that influence adaptation and the strategies that have been used to optimise this process. The review is based on an English language Medline search with secondary references obtained from key articles. There is evidence that adaptation occurs in humans. Adaptation is a complex process that results in response to nutrient and non-nutrient stimuli. Successful and reproducible strategies to improve adaptation remain elusive despite an abundance of experimental data. Nevertheless given the low patient survival and quality of life associated with other treatments for irreversible intestinal failure it is imperative that clinical research continues into the optimisation of the adaptation.
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Affiliation(s)
- A R Weale
- Department of Surgery, Southmead Hospital, North Bristol NHS Hospitals Trust, Westbury on Trym, Bristol BS10 5NB, UK.
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Weale AR, Edwards AG, Bailey M, Lear PA. Intestinal adaptation after massive intestinal resection. Postgrad Med J 2005; 81:178-84. [PMID: 15749794 PMCID: PMC1743223 DOI: 10.1136/pgmj.2004.023846] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patients with short bowel syndrome require long term parenteral nutrition support. However, after massive intestinal resection the intestine undergoes adaptation and nutritional autonomy may be obtained. Given that the complications of parenteral nutrition may be life threatening or result in treatment failure and the need for intestinal transplantation, a more attractive option is to wean patients off nutrition support by optimising the adaptive process. The article examines the evidence that after extensive small bowel resection adaptation occurs in humans and focuses on the factors that influence adaptation and the strategies that have been used to optimise this process. The review is based on an English language Medline search with secondary references obtained from key articles. There is evidence that adaptation occurs in humans. Adaptation is a complex process that results in response to nutrient and non-nutrient stimuli. Successful and reproducible strategies to improve adaptation remain elusive despite an abundance of experimental data. Nevertheless given the low patient survival and quality of life associated with other treatments for irreversible intestinal failure it is imperative that clinical research continues into the optimisation of the adaptation.
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Affiliation(s)
- A R Weale
- Department of Surgery, Southmead Hospital, North Bristol NHS Hospitals Trust, Westbury on Trym, Bristol BS10 5NB, UK.
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Benedetti E, Testa G, Sankary H, Sileri P, Bogetti D, Jarzembowski T, Abcarian H. Successful Treatment of Trauma-Induced Short Bowel Syndrome With Early Living Related Bowel Transplantation. ACTA ACUST UNITED AC 2004; 57:164-70. [PMID: 15284568 DOI: 10.1097/01.ta.0000061234.62927.6c] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND : Total parenteral nutrition (TPN) is a life-saving therapy for patients with short bowel syndrome. However, TPN is associated with a high incidence of serious complications, poor quality of life, and elevated cost. An attempt was made to avoid TPN-related complications associated with trauma-induced short bowel syndrome by using early living related donor bowel transplantation. METHODS : Three men 27 to 30 years of age with trauma-induced short bowel syndrome received early living related donor bowel transplantation using segmental ileal grafts. RESULTS : All the donors had an uncomplicated postoperative course. After a mean follow-up period of 40 months, all three recipients were alive and well, and did not require any TPN support. The ileal graft adapted perfectly to support fully the nutritional needs of young, active individuals. CONCLUSIONS : Early living related donor bowel transplantation is a successful treatment for trauma-induced short bowel syndrome. It is associated with a lower incidence of complications, better quality of life, and lower cost than long-term TPN.
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Affiliation(s)
- Enrico Benedetti
- University of Illinois at Chicago, Division of Transplantation, Chicago, Illinois 60612, USA.
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Holterman MJ, Holterman AL, Carrol R, John E, Testa G, Sankary H, Cohen M, Grevious M, Abcarian HA, Benedetti E. Living-related bowel transplantation to treat short bowel syndrome in a four-year-old child: a case report. J Pediatr Surg 2003; 38:1763-5. [PMID: 14666462 DOI: 10.1016/j.jpedsurg.2003.08.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE Short bowel syndrome (SBS) is an extremely challenging clinical problem in children. Although many patients can be maintained for a period of time on total parenteral nutrition (TPN), many of these children suffer from the morbidity and mortality associated with sequential central line infections, venous thromboses, and TPN-induced liver failure. Intestinal transplantation often is the only chance for long-term survival. Unfortunately, many children die every year waiting for size-matched cadaveric intestine to become available. METHODS After our success with living-related bowel transplantation in adults, the authors successfully transplanted 150 cm of maternal ileum into a 4-year-old 10-kg child with profound malnutrition from SBS and advanced TPN-induced liver failure. Because of the size mismatch, the abdominal cavity could not be closed primarily. The defect was covered with absorbable mesh and subsequently with skin graft. RESULTS The patient is home with excellent bowel and liver function, off hyperalimentation, and on a regular diet. No rejection has been encountered. CONCLUSIONS Living-related intestinal transplantation is a life-saving alternative to cadaveric intestinal transplantation in children with short bowel syndrome.
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Affiliation(s)
- M J Holterman
- Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
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