Case Of Small Bowel Transplantation Research Articles

Emergency removal of transplanted graft due to the failure of clinical treatment of serious acute rejection in case of small bowel transplantation: case report

Introduction: Intestinal transplantation is a complex procedure that has become more common in recent years. It can be performed isolated or with other organs of the digestive tract, which characterizes a multivisceral transplantation. Its indication mainly involves patients with irreversible intestinal failure, submitted or not to an enterectomy, and who have complications from parenteral nutrition. Among the main difficulties after transplantation is the immunosuppressive therapy, since the small intestine is an extremely immunogenic organ. Insufficient immunosuppression may cause graft rejection, but excessive immunosuppression may lead to Graft vs. Host Disease, where the intestine’s own immune cells attack Host organs. In Brazil, however, the practical experience with this type of surgery and with the management of immunosuppressive therapy is restricted because of the reduced number of small bowel transplants performed. Objective: To report a case of small bowel transplantation with graft rejection and necessity of surgical removal of the graft. Case Report: A male patient, 21 years old, presented a complicated acute appendicitis in July 2015, being submitted to appendectomy and right colectomy. After the operation, he developed thrombosis and intestinal infarction. This complication affected more than 90% of the patient’s small bowel, requiring extensive enterectomy. The patient developed short bowel syndrome and relied on parenteral nutrition. After 7 months in the home parenteral nutrition regimen, the patient underwent small bowel transplantation due to complications of parenteral nutrition. Immunosuppressive therapy was based on the use of tacrolimus. The patient presented no intercurrences until the 6th postoperative month, when he developed systemic histoplasmosis, staying 33 days in the intensive care unit. He presented resolution of the condition with itraconazole. At the 18th postoperative month, he was admitted with fever and intense diarrhea. The ileoscopy examination showed intestinal ulcers and loss of villi. Graft biopsies were consistent with severe acute T cell mediated rejection. The patient was transferred to our institution to treat the rejection. The combined use of increased tacrolimus, pulse therapy with methylprednisolone, use of thymoglobulin and use of monoclonal antibody against tumor necrosis factor alpha were not effective. The patient`s general condition deteriorated and he had to be submitted to urgent removal of the transplanted graft. The patient returned to the parenteral nutrition regimen and underwent reconstruction of the digestive tract with anastomosis between jejunum and transverse colon 5 months after grafting. Currently, he is in outpatient follow-up using home parenteral nutrition.

Correlation between major histocompatibility complex class I-related chain A gene alleles and graft rejection in small intestine, liver and kidney transplantation

To investigate the correlation between major histocompatibility complex (MHC) class I chain-related gene A (MICA) gene alleles matching rates and graft rejection in small intestine, liver and kidney transplantation. Genome DNA were extracted from blood samples or pathological sections collected from donors and recipients of living-related transplantation, included 4 cases of small bowel transplantation, 5 cases of liver transplantation and 6 cases of kidney transplantation. The correlation between MICA alleles matching rates and acute graft rejection was analyzed following 13 MICA alleles determination by polymerase chain reaction based on sequence-specific primers (PCR-SSP). HLA zygosity of all donors and recipients was confirmed to be half-matching. The recipients displaying higher matching rates of MICA alleles with donors showed lighter clinical and pathological rejection and longer survival time. On the contrary, recipients with lower matching rates of MICA alleles with donors showed severer clinical and pathological rejection and shorter survival time relatively. Matching rates of MICA alleles has negative relevance to acute rejection, and positive relevance to survival time of recipients in small bowel, liver, and kidney transplantation.

Anesthetic Management of Small Bowel Transplantation for Short Bowel Syndrome: A case report

General treatment of short bowel syndrome is long-term total parenteral nutrition (TPN). But long-term TPN therapy produces thrombus, infection and obstruction of central veins and results in the life-threatening complications. Recently we experienced first case of small bowel transplantation in a 57-year old female with only 30 cm jejunum and distal part of colon to the splenic flexure who was suffering short bowel syndrome due to previous wide resection of small bowel. We report successful anesthetic management of small bowel transplantation in the patient with short bowel syndrome who has been suffered from life threatening complications due to long-term TPN therapy.

INTESTINAL DISTRIBUTION AND LEAKAGE OF HYALURONAN AFTER SMALL BOWEL TRANSPLANTATION

The accumulation, distribution and luminal secretion of hyaluronan (hyaluronic acid; HA) was demonstrated at different times after small bowel transplantation experimentally, and in one clinical case. Semiallogenic or semisyngenic rat models were used to elicit either unidirectional graft rejection or graft-versus-host disease. During graft rejection a cellular infiltrate and edema appeared in the lamina propria in the crypt are where an accumulation of HA was also demonstrated. There was progressive accumulation of HA in the small bowel during rejection and on day 6 there was a three-fold increase compared to the values in syngenic grafts. The increase in tissue HA was paralleled by an increase in the total water content of the rejecting graft. Measurements of the luminal secretion of HA in rejection grafts at day 6 revealed a five fold increase at this time. In specimens from animals suffering from GVHD, no significant changes in water of HA content and distribution were observed until day 12. In a clinical case of small bowel transplantation in a 14 months oldchild, luminal secretion of HA was measured in the graft by using a segmental intestinal perfusion technique. A more than 30 fold increase of secreted HA was noted, which was directly paralleled by clinical and histological signs of graft rejection. The data suggest that accumulation of HA might contribute to the pathophysiology of the transplantation edema and that HA might be of potential diagnostic value for monitoring purposes after small bowel transplantation.