First Small Intestine Transplant in Western India: An Initial Experience (original) (raw)
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India’s first successful intestinal transplant: The road traveled and the lessons learnt
Indian Journal of Gastroenterology, 2014
Intestinal transplant is a therapeutic challenge not just surgically but also logistically because of the multidisciplinary expertise and resources required. A large proportion of patients who undergo massive bowel resection and develop intestinal failure have poor outcome, because of inability to sustain long-term parenteral nutrition and limited availability of intestinal and multi-visceral transplantation facilities. We report the first successful isolated intestinal transplant from India. Keywords Isolated intestinal transplant. Line infection. Long-term parenteral nutrition. Short gut syndrome Case A 27-year-old software engineer underwent massive bowel resection of the entire intestine except about 30 cm of small bowel due to mesenteric vein thrombosis 4 years ago. After resection, he was on parenteral nutrition (PN) through chemoport. Over the next 2 years, he had seven episodes of line sepsis, two of which were potentially life threatening. Over 4 years, he lost 36 kg, had poor quality of life, loss of self-esteem, and developed suicidal tendencies. He was evaluated (Table 1) and found suitable for an isolated intestinal transplant. The donor was a 21-year-old man who had head injury in a road accident in the same city. He was hemodynamically stable with normal hematology, serology, and biochemistry except raised sodium of 162 mmol/L. The small intestinal graft was accepted after confirmation of negative T and B cell lymphocytic crossmatch and correction of sodium and retrieved in the standard fashion. In the recipient, adhesiolysis was performed; the distal ileal remnant and the proximal half of the colon were resected. Under thymoglobulin (ATG) induction, intestinal graft was implanted with inflow from infra-renal aorta and outflow into portal vein using vascular conduits, resulting in uniform reperfusion. Bowel continuity was established by jejunojejunal and ileocolic two-layer anastomoses, leaving a 20-cm "chimney ileostomy". He was given enteral feeds at 2 weeks and oral diet at 3 weeks after transplant when PN was stopped. He had two episodes of rejection in the first 6 weeks, which responded to ATG and steroids, respectively. After discharge, he developed chylous ascites, and required three re-admissions for intercurrent problems, all of which settled on conservative management. He is well 10 months after the transplant. Conclusions This is the first reported case of successful intestinal transplantation from India. Dedicated teams to manage long-term PN, A.
Small bowel transplantation – the latest developments
Medicine, 2011
Intestinal transplantation has become a routine clinical procedure for selected patients. Over the last 10 years patient survival figures have improved considerably and are now approaching those receiving organs such as liver, lung and heart. Patient selection has improved and immunosuppression has been enhanced by the introduction of lymphocyte modulating antibody therapy combined with less potent maintenance immunosuppression. The indications for intestinal transplantation remain conservative at present and largely reserve this procedure for patients who have life threatening complications of parenteral nutrition or require surgical procedures that make simultaneous or subsequent transplantation advantageous. However, as survival figures improve the indications are beginning to broaden to include consideration of quality of life. Survival after transplantation is approaching that associated with uncomplicated parenteral nutrition and if this trend continues it may replace parenteral nutrition as the treatment of choice for patients with irreversible intestinal failure. This article describes the current indications for intestinal transplantation and the current results of the procedure. Guidelines for referring patients for transplantation assessment and for the management of the sick transplant patient are given. The need to consider referral of patients at an early stage to allow timely assessment for transplantation is also discussed.
CADAVERIC SMALL BOWEL AND SMALL BOWEL-LIVER TRANSPLANTATION IN HUMANS 1,2
Transplantation, 1992
Five patients had complete cadaveric small bowel transplants under FK506 immunosuppression, one as an isolated graft and the other 4 in continuity with a liver. Three were children and two were adults. The five patients are living 2-13 months posttransplantation with complete alimentation by the intestine. The typical postoperative course was stormy, with sluggish resumption of gastrointestinal function. The patient with small intestinal transplantation alone had the most difficult course of the five, including two severe rejections, bacterial and fungal translocation with bacteremia, renal failure with the rejections, and permanent consignment to renal dialysis. The first four patients (studies on the fifth were incomplete) had replacement of the lymphoreticular cells in the graft lamina propria by their own lymphoreticular cells. Although the surgical and aftercare of these patients was difficult, the eventual uniform success suggests that intestinal transplantation has moved toward becoming a practical clinical service.
Transplantation Proceedings, 2008
Intestinal failure is the patient's inability to maintain hydroelectric and nutritional support by the digestive route, arising from massive enterectomy or diseases in which the bowel is incapable of adequately absorbing fluids and nutrients. Patients with intestinal failure associated with short bowel syndrome (SBS) and with other functional diseases with malabsorption or with total parenteral nutrition-related complications (recurrent sepsis and thrombosis of one or more deep venous accesses) are candidates for small bowel transplantation (SBT), which can be an isolated small bowel, a combined liver and small bowel, or a multivisceral graft. At our institution, three isolated SBTs were performed as our initial experience with this transplant.
Small intestine transplantation today
Langenbeck's Archives of Surgery, 2007
Introduction Intestinal transplantation has become a lifesaving therapy in patients with irreversible loss of intestinal function and complications of total parenteral nutrition. Discussion The patient and graft survival rates have improved over the last years, especially after the introduction of tacrolimus and rapamycin. However, intestinal transplantation is more challenging than other types of solid organ transplantation due to its large amount of immune competent cells and its colonization with microorganisms. Moreover, intestinal transplantation is still a low volume procedure with a small number of transplanted patients especially in Germany. A current matter of concern is the late referral of intestinal transplant candidates. Conclusion Thus, patients often present after onset of lifethreatening complications or advanced cholestatic liver disease. Earlier timing of referral for candidacy might result in further improvement of this technique in the near future.
An isolated complete intestinal transplantation in an adult: A complicated postoperative course
A 31-year-old black male was referred to the Universiry of Pittsburgh Medical Center five months after he lost his entire small bowel. (Fig. 1) The patient had multiple gunshot injunes to the abdomen and was placed on total parenteral nutrition (TPN) after unsuccessful multiple anempts to reconstruct the main superior mesemeric vessels. Because continuiryof the gastrointestinal tract was not restored at the time of surgery. induced vomiting was the only wav to drain the gastroduodenal and biliary secretions. At the lime of initial evaluation. the biochemical liver function tests were good and the patiem was accepted as a candidate for an isolated small intestinal transplantation (SBTx). Donorlnjormarion. On May 2.1990, a suitable donor became available and the whole small bowel was transplanted. The donor was young (36 years old). Caucasian. of the opposite sex and smaller in size compared to the recipient. The graft was ABO identical (0 +ve) , HLA incompatible and the cytotoxic cross match was negative. Selective decontamination of the donor's gut was attempted utilizing Amphotericin B. gentamycin and polymyxin E with no efforts to alter the graft lymphoreticular tissue with either OKT3 , AlG or other modalities. The whole small bowel was harvested by Dr. Starzl and was preserved by simple immersion in an ice bath without vascular flushing. The intestinal lumen was irrigated with cold lactated Ringer's solution. and the graft was preserved for 10.5 hours. Recipient Operarion. Extensive adhesions were evident at the time of surgery because of the previous multiple abdominal operations. The gallbladder was injured during kocherization of the duodenal stump and dissection of the transverse colon which necessitated cholecystectomy. The technique of the graft implantation was similar to that originally used by Lillehei in dogs more than 30 years ago, except that arterialization was with a free segment of the recipient internal iliac artery that was interposed between the superior mesenteric artery (SMA) of the graft and the recipient infrarenal aorta. (Fig. 2) After tedious dissection. the distal stump of the recipiem superior mesemeric vein (SMV) was found and anastomosed to the graft SMV using a segment of the donor iliac vein as an interposition graft. The proximal segment of the graft jejunum was anastomosed side-to-side to the recipient duodenal stump. and the intestinal graft was vented at both ends by a chimney-rype proximal jejunostomy and distal ileostomy. Both vents allowed closed monitoring of the graft and adequate early decompression of the GI tract. COntinuiry of the alimentary