LIVING RELATED SMALL BOWEL TRANSPLANTATION. REPORTING EXPERIENCES OF 2 CASES.

Abstract

P615 Aims: We have recently performed the living-related small bowel transplantation for 2 patients with short-bowel syndrome at Tohoku University Hospital. This article reports our experiences of both cases. Methods: The first patient was a 14-year-old boy with TPN-dependent short-gut syndrome associated with hypoganglionosis of the entire intestine (body weigh 25 kg). He received a bowel graft from 43-year old mother (body weigh 53 kg). The second patient was a 27-year-old female (body weight 41 kg), who had massive enterectomy due to volvulus and became short-gut syndrome at the age of seven, developed vitamin deficiency and severe metabolic disorder as a result of long-term TPN. She recently underwent living-related bowel transplantation from 57-year-old mother (body weight 50 kg). Blood types were ABO identical, cytotoxic cross match were negative, and CMV status were positive to positive in both cases. The bowel graft, 150 cm and 210 cm in length (up to one-third of the donor bowel) was harvested from the donor distal ileum more than 30 cm away from the ileocecal valve. The distal ileum was used in both cases because preoperative angiogram showed that it has the longest vascular arcade. The graft vessels were connected to infrarenal aorta, and inferior vena cava. The immuno-suppressive regimen consisted of daclizumab, tacrolimus, and proper steroid. The blood trough level of tacrolimus maintained between 20-25 ng/ml for the first 2 months, followed by 15-20 ng/ml thereafter. 2 mg per body weight (kg) of daclizumab was administered on day of operation, and same dosage has been repeated once for 2 weeks. The graft surveillance for acute cellular rejection (ACR) was accomplished using zoom endoscopy and mucosal biopsy. Results: The first patient developed progressive ACR on POD-9 and required a 14-days course of OKT-3 injection. OKT-3 therapy was quite effective. Two months after transplantation (POD-57), he became off-TPN only requiring fluid supplementation of watery stomal output, tolerating oral intake with the full functioning graft. He discharged 4 months after transplantation (POD 112). The donor had no complications and discharged 10 days after operation. The second patient had no episode of ACR for the first 2 weeks after transplantation and enteral feeding was started on POD 11 with functioning graft. Metabolic disorder has dramatically improved after bowel transplantation. The donor discharged 10 days after operation with no complications. Conclusions: The living-related bowel transplantation could successfully be performed, and with a recent advantage in immunosuppressants and postoperative care, it can be an extreme choice of treatment for patients with short-bowel syndrome.