Indications et résultats de la transplantation intestinale chez l’adulte

Abstract

Optimised home parenteral nutrition is still, after 35 years of progress, the "gold standard "for benign but chronic intestinal failure. better recognition of chronic intestinal failure, in its multiple facets, is needed to improve Home Parenteral Nutrition by adding associated treatments such as intestinal trophic factors, rehabilitative surgery (reestablishment of colonic continuity, reverse jejunal segment in severe short gut type II) and/or reconstructive surgery (intestinal transplantation for end-stage intestinal failure). Intestinal transplantation is now a mature therapy with formal indications, especially in case of failure of Home Parenteral Nutrition (mainly Home Parenteral Nutrition-associated severe liver disease), where combined Liver-intestine transplantation is indicated before end-stage liver failure occurs. For high-risk patients, 'preemptive' intestinal transplantation alone should be discussed before home parenteral nutrition-related complications occur. Even, if the results in terms of patient survival have improved over the past 20 years, the 5-year survival rate still does not exceed 50%. Thus, each case should be discussed in a dedicated tertiary center. The ESPEN Home Artificial Nutrition Working Group conducted a survey in 2004 to assess potential candidates for intestinal transplantation in France, among the adult population of patients with home parenteral nutrition. The prevalence of potential candidates for intestinal transplantation was estimated at about 20% (about 40 new adult cases per year). Even though surgical techniques for isolated intestine, liver-intestine, and multivisceral transplantation were developed in the 1960s, very few patients were transplanted before 1990, because of inadequate initial immunosuppressive regimens. most patients died within days or months after Intestine transplantation. The discouraging results of the first clinical trials were due to technical complications, sepsis, and the failure of conventional immunosuppression to control rejection. By 1990, the development of tacrolimus-based immunosuppression, as well as improved surgical techniques, the increased array of potent immunosuppressive medications, infection prophylaxis, and better patient selection helped to improve actuarial graft and patient survival rates for all types of intestine transplantation. In adult intestinal transplantation, three kinds of graft can be proposed: isolated small bowel, combined liver and small bowel, and multivisceral transplantation. In isolated small bowel transplantation, the length of the graft ranges between 1.5 and 2 meters, but depends on the size of the recipient (and the abdominal cavity volume, which is reduced). The graft is anastomosed with the recipient's duodenum or remnant proximal jejunum. the distal part of the small bowel graft is on a temporary stoma, in order to allow biopsies for early detection of rejection. Vascular anastomoses are usually performed directly on the aorta for the superior mesenteric artery and either the recipient's portal vein or vena cava for the donor superior mesenteric vein. In combined liver and intestinal transplantation, one venous anastomosis is avoided because the graft is in one piece. Finally, one specificity of this transplantation is the fact that it usually concerns patients with numerous previous abdominal operations and with total or subtotal enterectomy. Thus, the residual abdominal cavity is usually very small, and this can be a major problem for graft insertion. For this reason, abdominal closure is performed with a temporary prosthesis, because even cutaneous closure remains impossible if a compartment syndrome is to be avoided.