SMALL INTESTINAL TRANSPLANTATION IN (SIT) IN CHILDREN

Abstract

After experiments on piglets and rats SIT using Cyclosporine A (CsA) and after obtaining consent form from parents, we performed six SIT in children (6mths-9yrs) with short gut syndrome on home TPN for 0.5 to 6 years. All but one donor and recipients were isoblood group ABO, with negative cross match reaction. Graft were harvested on brain dead neonates (n=2) or children 6-17 yrs, 110 ± 10 cm of jejuno ileum underwent both vascular and luminal washing using Collins (n=3) or UW (n=3). After aorta and inferior vena cava anastomosis total ischemic time ranged from 1 hr 20 to 6 hr 30. Graft was anastomosed on proximal end; both distal graft and own intestine were exteriorized as stomas. Initial immunosuppression included solumedrol 2 mg/Kg/d and Cyclosporine as a contlnous infusion for RIA serum levels 200-300 ng/ml. Antilymphoglobuline (ALG) (5 mg/Kg/d) for 14 days were added in the last 4 cases. Systemic antibiotics and total decontamination of the graft are associated. The first graft was removed after 8 hours for ischemia; the child was discharged on home PN. Early (< 15 days) or delayed (2-6 mths) acute graft rejection (GR) occured in all cases. Late clinical symptoms included increased ileostomy drainage while histologic pattern changed earlier including progressively : T cell infiltrates (CD4+, CD8+, CD25+), increased HLA DR expression by crypts enterocytes, villi oedema, destruction of crypt and surface epithelium, crypt sbcesse and finally mucosal sloughing. GR was treated with ALG or OKT3 but leaded to graft removal in 3 cases 3 wks to 6 mths after SIT. One graft was removed on the 17th mth because of chronic rejection. Four graft were progressively used from the 4th wk tolerating up to 90 % of total energy intakes, like in one patient still living with the graft for 10 mths. Functionnal assesment included baryum transit, enzyme activities, and absorption tests. Those results show that SIT is possible but depending on important immunosuppression. No GVH reaction was observed. GR can be limited by repeated immunohistochemical study and early treatment.