Irreversible Intestinal Failure Research Articles

Intestinal re-transplantation: indications, techniques and outcomes.

The field of intestinal transplantation has shown significant growth and has become the gold standard therapy for patients that suffer from the complications of total parenteral nutrition due to irreversible intestinal failure. In the early years of intestinal transplant, retransplantation was associated with extremely high morbidity and mortality. The purpose of this review is to summarize recent encouraging reports, showing significant improvement in outcomes after intestinal retransplantation. Recent studies at large volume centers have reported significant progress in patient and graft survival after intestinal retransplantation. Recent literature described the most common indications for retransplantation, surgical techniques, timing of graft enterectomy, immunologic monitoring, and complications. Improvement in outcomes due to advances in immunosuppression management and the importance of liver-containing grafts are also described. Improving early to midterm patient and graft survival has made consideration for intestinal retransplantation even more necessary. Current clinical evidence supports the benefit of intestinal retransplantation in well selected recipients. Initial immunosuppression protocols, technical modifications, proper timing of enterectomy, and improved infectious disease monitoring have contributed to improved outcomes.

Pre-emptive Intestinal Transplant: The Surgeon's Point of View.

Pre-emptive transplantation is a well-established practice for certain types of end-organ failure such as in the use of kidney transplantation. For irreversible intestinal failure, total parenteral nutrition (TPN) remains the gold standard, due to the suboptimal long-term results of intestinal transplantation. As such, the only role for pre-emptive transplantation, if at all, will be for patients identified to be at high risk of complications and mortality while on definitive long-term TPN. In these patients, the timing of early listing and transplantation could become life-saving, taking into account that mortality on the waiting list is still the highest for intestinal candidates. The development of simulation models or pre-transplant scoring systems could help in selecting patients based on potential outcome on TPN or with transplantation, and recent reports from high-volume centers identify few underlying pathologic conditions and some TPN complications as at higher risk of increased morbidity and mortality. A pre-emptive transplant could be used as a rehabilitative procedure in a well-selected case-by-case scenario, among TPN patients at risk of liver failure, repeated central line infections, mesenteric infarction, short bowel syndrome (SBS) <50cm or with end stoma, congenital mucosal disease, desmoid tumors: These conditions must be carefully evaluated, not to underestimate the clinical stage nor to over-estimate the impact of a temporary situation. At the present time, diseases with a variable and unpredictable course, such as intestinal dysmotility disorders, or quality of life and financial issues are still far from being considered as indications for a pre-emptive transplant.

Ultra-short bowel is an independent risk factor for liver fibrosis in adults with home parenteral nutrition.

Intestinal failure-associated liver disease is rare in adults and risk factors are unclear. The aim of this study was to determine risk factors of liver fibrosis in adults receiving home parenteral nutrition for intestinal failure and its impact on survival. We retrospectively analysed patients with irreversible intestinal failure who underwent a liver biopsy between 2000 and 2013. Significant liver fibrosis was defined as ≥F2 according to NASH-CRN score. Thirty-two patients (46years [29-60]) underwent liver biopsy 55months (9-201) after beginning parenteral nutrition. Twenty-six patients (81%) had a short bowel (gut<200cm), including 12 (37%) with an ultra-short bowel (gut<20cm). Eighteen patients (56%) had liver fibrosis (4F2, 10F3, 4F4), associated with steatohepatitis (72%) and/or cholestasis (17%). Factors associated with occurrence of liver fibrosis included ultra-short bowel (83% vs 13% at 60months; P<.001), alcohol consumption (73% vs 33% at 60months; P<.001) and diabetes (80% vs 34% at 60months; P=.01). Home parenteral nutrition composition, quantity, or duration, episodes of sepsis, abandoned bowel segment were not associated with fibrosis. Ultra-short bowel [risk ratio 12.4, P<.001] and alcohol consumption [risk ratio 7.4, P=.009] independently predicted the development of liver fibrosis on multivariate analysis. After a median follow-up of 118months (72-155), survival was poorer in patients who developed liver fibrosis than in those without (59% vs 92% at 120months; P=.02). An ultra-short bowel and alcohol consumption are independent risk factors for liver fibrosis in adults requiring HPN.

Improving Intestinal Transplant Long Term Outcome by Tele-Care Program

Introduction: Intestinal transplantation has recently become an accepted therapy for selected patient with irreversible intestinal failure in Taiwan since 2012. Outcome of intestinal transplantation have continued to improve in recent years. Due to our center is the first qualified hospital to implement intestinal transplantation. Most transplantation recipient was referred from a distant location. After transplantation, they need travel long distances for medical clinical follow up. That will affect the outcome of intestinal transplantation outcome. To reduce unnecessary patient travel, and thereby reduce the travel cost and inconvenience of consultations without compromising the quality of patient follow up program. We set a tele-care program to provide an integrated delivery system for follow up intestinal transplant patient. Methods: Tele-care program including: tele-consultation, tele-monitoring and tele-education. Patient was instructed to add the connection list of Tele-care program and address data including current body weight, blood pressure ileostomy output and defecation frequency. Stool nature was report by photography. Tele-monitoring responsibility for transplant coordinator involved daily monitoring of data and initiation of contact with patient. Discuss the data to transplant team member and inform patient if any problem. Patient were encouraged to discuss any concerns related to self-care or acquire advice to tele-monitoring. Most patients common satisfied to tele-consultation by real-time communication which remains a face-to-face or picture consultation in their mobile phone. The LINE communication offer free massage and phone consultation held 24 hours by transplant coordinator nurse and that service was free cost for patient. Results: From 2011–2016, 15 intestinal transplantation were performed and every patient has used these services for home care. The utility rate of medical care consultation was higher than previous traditional care model because low communication cost and effectiveness. Conclusion: The use of LINE communication to provide Tele-Care program can offer the patient with intestinal transplantation an effectiveness and continued care after discharge. That helps reduce the medical and patient cost of post intestinal transplant follow up and enhance caregiver and patient confident. The new program provide patient assessment and education, and enhance positive patient outcomes, including patient compliance.

Paneth Cell Alterations After Intestinal Transplantation and During Graft Rejection

Introduction: Intestinal transplantation (ITx) has become an accepted treatment for patients with irreversible intestinal failure, but remains a challenging procedure. Acute rejection is the most common complication. Ischemia reperfusion injury (IRI) plays a pivotal role in the cascade leading to rejection. We have shown that Paneth cells, important gatekeepers of intestinal crypts, are highly susceptible to IRI in humans. Therefore, our aim was to study Paneth cell homeostasis in IRI and rejection in ITx patients. Methods: Archived endoscopic mucosal biopsies of 33 ITx patients were used, and clinical information was collected. Consecutive biopsies were stained for Paneth cell marker lysozyme and apoptotic marker M30 to visualize antimicrobial expression and apoptotic cells at reperfusion (T0), and during the first week (W1), month (M1), and year (Y1) after ITx, as well as prior to, during, and after a rejection episode. The number of lysozyme-positive and M30-positive cells per crypt, and lysozyme intensity were quantified by two independent observers. Results: Within W1 after ITx, there was a significant decrease in lysozyme intensity (P<0.05), and a tendency towards lower Paneth cell number per crypt (P=0.09) compared to T0. Within Y1, the Paneth cell number was comparable to T0, and increased compared with W1 and M1 (P<0.01). Prior to rejection, lysozyme intensity was significantly reduced compared with T0 (P<0.01). Higher lysozyme expression was observed after rejection compared with levels prior to (P<0.05), and during rejection (P=0.08). Paneth cell numbers were increased after a rejection episode compared with levels prior to, and during rejection (P<0.05). Conclusion: This study shows reduced Paneth cell numbers and antimicrobial expression during the first week after ITx, as well as prior to, and during a rejection episode. These data suggest an interplay between innate immunity, reduced antimicrobial defense mechanisms, and alloimmune response.

Absence of Oesophageal Varices in Children with Splenomegaly and Advanced Intestinal Failure Associated Liver Disease

Objectives of the study: Children with splenomegaly and portal hypertension due to primary liver disease demonstrate presence of gastro- oesophageal varices (GOV) on oesophago-gastroduodenoscopy (OGD). Intestinal failure – associated liver disease (IFALD) is a secondary liver disease developing in 40% to 60% of infants requiring long term parenteral nutrition for irreversible intestinal failure. A proportion of these children develop life threatening complications of cirrhosis and portal hypertension. Assessment of portal hypertension is important to determine the type of intestinal transplantation (ITx) offered as a life saving option. Intestinal transplantation is the only life saving option for these children. During intestinal transplant assessment within our programme, we assessed the children for the presence of GOV. Aim: To evaluate the incidence of GOV in children with IFALD referred for small bowel transplant assessment. Methods: Medical records of 122 patients who underwent assessment for small bowel transplant (SBtx) over the last 12 years (Sept 04 to Dec 16) were reviewed. Data detailing spleen size, splenomegaly, liver biopsy with staging of hepatic fibrosis and presence of GOV on oesophago-gastroduodenoscopy (OGD) was recorded. Results: 118/122 children assessed were included in the study as 4 children did not have ultrasound scan (USS). 98/118 (83 %) children had splenomegaly on USS. 54/98 (55.1%) children underwent OGD and oesophageal varices were present in 11 children (20.3%), of which only 10 had Grade 1 and one had Grade 3 varices. Of the 20 patients with a normal sized spleen, 15 underwent an OGD- no varices have been detected. 56 children had an OGD and a liver biopsy performed at the same time. 51/56 patients had fibrosis, 26/51 (50.9 %) were graded as mild fibrosis on liver biopsy, and 8/56 (14.2 %) of them had oesophageal varices (grade 1). Moderate to severe fibrosis was noted in 25/51 (49%) children and only 2/25 (8%) children had GOV, all Grade I. Summary and Conclusion: Children with IFALD, who have a normal size spleen did not have varices at OGD and therefore do not require endoscopy to stage their liver disease. In children with IFALD, splenomegaly is common and GOV are infrequent. Their presence does also not correlate with the degree of liver-fibrosis. In conclusion, USS evidence of splenomegaly alone is a poor predictor for GOV and additional tests such as platelet count, hepatic elastography may improve the assessment of portal hypertension in children with intestinal failure associated liver disease.

Long-term outcomes of living-related small intestinal transplantation in children: A single-center experience.

Pediatric patients with irreversible intestinal failure present a significant challenge to meet the nutritional needs that promote growth. From 2002 to 2013, 13 living-related small intestinal transplantations were performed in 10 children, with a median age of 18months. Grafts included isolated living-related intestinal transplantation (n=7), and living-related liver and small intestine (n=6). The immunosuppression protocol consisted of induction with thymoglobulin and maintenance therapy with tacrolimus and steroids. Seven of 10 children are currently alive with a functioning graft and good quality of life. Six of the seven children who are alive have a follow-up longer than 10years. The average time to initiation of oral diet was 32days (range, 13-202days). The median day for ileostomy takedown was 77 (range, 18-224days). Seven children are on an oral diet, and one of them is on supplements at night through a g-tube. We observed an improvement in growth during the first 3years post-transplant and progressive weight gain throughout the first year post-transplantation. Growth catch-up and weight gain plateaued after these time periods. We concluded that living donor intestinal transplantation potentially offers a feasible, alternative strategy for long-term treatment of irreversible intestinal failure in children.

Choice of Allograft in Patients Requiring Intestinal Transplantation: A Critical Review.

Intestinal transplantation (ITx) is indicated in patients with irreversible intestinal failure (IF) and life-threatening complications related to total parenteral nutrition (TPN). ITx can be classified into three main types. Isolated intestinal transplantation (IITx), that is, transplantation of the jejunoileum, is indicated in patients with preserved liver function. Combined liver-intestine transplantation (L-ITx), that is, transplantation of the liver and the jejunoileum, is indicated in patients with liver failure related to TPN. Thus, patients with cirrhosis or advanced fibrosis should receive a combined allograft, while patients with lower grades of liver fibrosis can usually safely undergo ITx. Reflecting their degree of sickness, the waitlist mortality rate and the early posttransplant outcomes of patients receiving L-ITx are worse than IITx. However, L-ITx is associated with better long-term graft and patient survival. Multivisceral transplantation (MVTx), that is, transplantation of the organs dependent on the celiac axis and superior mesenteric artery, can be classified into full MVTx if it includes the liver and modified MVTx if it does not. The most common indications for MVTx are extensive portomesenteric thrombosis and diffuse gastrointestinal pathology such as motility disorders and polyposis syndrome. Every patient with IF should undergo a multidisciplinary evaluation by an experienced ITx team.

New mutations of EpCAM gene for tufting enteropathy in Saudi Arabia

Background/Aim:Tufting enteropathy (TE) is a rare cause of congenital intractable diarrhea in children. It often results in an irreversible intestinal failure and total parenteral nutrition (TPN) dependency; eventually, intestinal transplantation may be necessary. Data on TE from the Middle East are scarce; therefore, our aim of conducting this study was to clarify the clinical, histopathologic, and molecular features of TE in Saudi children.Patients and Methods:This was a retrospective chart review of four children with TE who presented between January 2011 and December 2013 to King Fahad Specialist Hospital-Dammam (KFSH-D). The diagnosis of TE was suspected based on characteristic histopathologic intestinal biopsy findings and confirmed by EpCAM gene testing.Results:Molecular testing identified two novel mutations in the EpCAM gene in our patients. These mutations were associated with severe phenotype of the disease characterized by very early onset (median of 2 weeks of life), TPN dependency, and death during early childhood. Two patients died due to central line-related complications. Two patients were referred for intestinal transplantation due to loss of intravenous access in one and progressive liver disease in the other.Conclusion:Mutations in EpCAM gene in Saudi children are characterized by severe phenotype and poor outcome.

Isolated Small Bowel Transplantation in Turkey: A Single Center Experience Running Title: Isolated Small Bowel Transplantation in Turkey

Background SBTx has become a feasible therapeutic option for patients with irreversible intestinal failure. Increase in the number and in the improvement of the patient and graft survival in SBTx has a slow course when compared to other solid organ transplantation. Aim The aim of this study is to analyze 25 isolated SBTx performed since 2003 at a single center. It also aims to compare the patient and graft survivals rate during the early (before 2010) and late (after 2010) period. Materials and Methods Medical charts of 24 patients were analyzed retrospectively. To compare the center’s experience during a twelve year period, the results were divided into two groups (before (n:7) and after 2010 (n:18)). At the appropriate time, data were reported as mean± standard deviation, median, and range. Kaplan Meier method was used for the survival analysis of the graft and the patients. Results Median age of the patients was 39 (min 6 months, max: 56 yr). Six of them were in the pediatric age group. Compared to before 2010, graft survival rates increased from 28.1% to 53.8% in 3 months, from 28.6% to 35.9% in 6 months, and from 14.3% to 29.9% in one year after 2010. At the same period, patient survival rate increased from 57.1% to 72.2% in 3 months, from 28.6% to 38.9% in 6 months, and from 14.3% to 33.3% in one year. In the pediatric age group, patient and graft survival rates were 85.7% in 3 months, 71.4% in 6 months, and 71.4 % in 1 year. Conclusion SBTx is an effective treatment choice for selected patients with intestinal failure. Although patient and graft survival rates were improved after 2010 in our center, it was inferior. Patient and graft survival rates in pediatric SBTx are favourable and promising.

Intestinal Failure and Transplant: The Australian Experience (2009 to 2014)

BackgroundA joint adult and pediatric intestinal transplant (ITx) program for Australia was developed in 2009 to provide life-saving ITx to patients with irreversible intestinal failure (IF). We aimed to analyze the outcomes of patients treated by our service over the past 5 years. MethodsA retrospective medical record review was conducted on all IF patients referred to our service. Patient demographics, underlying disease, nutrition support, TPN complications, and current transplant program status were evaluated. ResultsFifty-seven patients (35 adults, 40.4 ± 12.4 years; 22 children, 6.3 ± 4.3 years) throughout Australia and New Zealand have been referred. Leading causes of IF were short bowel syndrome followed by pseudo-obstruction. Forty patients (70%) exhibited at least 1 life-threatening complication of PN at referral: liver failure, impending loss of venous access, and/or recurrent line sepsis. Three patients have undergone ITx with 100% survival (median follow-up, 1161 days). Four patients (8%) are listed for transplant, 6 patients (12%) are awaiting transplant assessment, and 4 patients (8%) have died (2 while awaiting transplantation, 2 during assessment period). Causes of death included sepsis and intracranial bleed. Two-thirds of all referred patients (n = 40) were deferred or rejected from wait-listing. ConclusionsAfter 5 years of establishing the first dedicated ITx program in Australia and New Zealand, early results indicate that ITx is an available and life-saving option for IF patients in these countries. Current barriers to ITx in Australia include a shortage of appropriate donors and a high rate of donor-specific antibodies among potential recipients. Growing awareness of the service and early referral to assist appropriate patient selection will aid in the program's success.

OP‐4 ADVANCES IN TISSUE ENGINEERING TO REGENERATE THE INTESTINAL EPITHELIUM

Introduction:Irreversible intestinal failure (IF) due to anatomical or functional loss is a devastating condition is associated with significant morbidity and mortality. Patients referred for intestinal transplantation suffer low survival rates due to the high graft‐rejection rate and sepsis as a consequence long‐term immunosuppression. These clinical challenges reveal an urgent need for research into new treatments for IF. Here, we present recent advances in our work on intestinal tissue engineering.Methods:Ethical approval is in place to collect intestinal tissue from patients at Great Ormond Street Hospital. Intestinal crypts were isolated and organoids were cultured as previously described. Decellularization of whole intestinal sections was performed using 2 cycles of the Detergent Enzymatic Treatment (DET) as previously reported. Organoids were cultured on the epithelial surface of the acellular matrix in vitro for 10 days. Cell survival was analysed by histology, immunofluorescence, immunohistochemistry and electron microscopy techniques.Results:Intestinal crypts from the small intestine and colon were successfully isolated from endoscopic biopsies and cultured in order to generate 3 dimensional organoids. The presence of goblet cells and enterocyte cells were confirmed on immunohistochemistry. Whole sections of intestine of varying lengths were successfully decellularized and assessed using H&amp;E staining and scanning electron microscopy. Organoids were seeded onto the epithelial surface of the acellular intestinal matrices and allowed to engraft for a period of 10 days in vitro. The formation of a neo‐epithelium with evidence of a microvillus brush border was evident after 10 days in culture. Furthermore, the cells had successfully migrated into the crypt domains of the matrix.Conclusions:We demonstrate the potential of tissue engineering for intestinal failure by combining organoid cultures with decellularization expertise. Our results confirm human intestinal organoids to be the ideal source of progenitor cells to regenerate the intestinal epithelium, with potential clinical applications for transplantation.

Visceral Transplantation for End-Stage Crohnʼs Disease: 25 Years of Experience at a Single Center

Introduction: Intestinal and multivisceral transplantation has recently evolved and more frequently utilized for patients with irreversible intestinal and TPN failure. End-stage Crohn's disease (CD) has been the second leading indication in adults. This is the largest worldwide series of CD patients who received visceral transplantation at a single center. Long-term efficacy is addressed with special reference to disease recurrence. Methods: Over 25 years, 57 CD patients underwent visceral transplantation for a recalcitrant disease with a mean duration of 5+5 years. All patients failed TPN due to multiple line infection (94%), limited venous access (83%) and significant liver damage (80%). Male to female ratio was 1:1.7 with a mean age of 43+10 years. All patients underwent multiple abdominal operations with proctocolectomy in 37 (65%). Simultaneous hepatic replacement was required in 12 (21%) patients with a mean serum bilirubin of 9+11mg/dl. Remaining 45 (79%) received liver-free visceral allografts with intestine alone in 43 and modified multivisceral graft including stomach, duodenum, pancreas, and intestine in 2. Rejection prophylaxis was tacrolimus based with induction therapy in 8 (14%) and recipient pretreatment in 37 (65%) recipients. Results: With a mean follow-up of 54+48 months, 33 (58%) patients were alive with a retransplantation rate of 7%. Rejection was the leading cause of graft loss with an overall incidence of 56%. Actuarial patient survival was 90% at 1 year, 56% at 5 years, and 43% at 10 years with respective graft survival of 86%, 53%, and 42%. Inclusion of donor liver was associated with better outcome with a 10-year survival rate of 57%. Recipient pretreatment significantly improved patient survival with respective 1, 5, and 10-year survival rates of 92%, 61% and 61%. All survivors achieved full nutritional autonomy. Disease recurrence was histologically documented in 4 (7%) allografts at 3, 15, 18, and 19 months from date of transplant with no impact on graft function. There was no significant (P=0.6) difference in survival between CD and non-CD patients with a higher cumulative risk of rejection induced graft loss among CD patients. Conclusion: Visceral transplantation is an effective life-saving treatment for patients with end-stage CD. Disease recurrence is low with no significant impact on functional survival.

Outcomes of isolated small bowel transplants in a single UK centre

Small bowel transplantation is a curative procedure for the treatment of irreversible intestinal failure with the complications of parenteral nutrition or for extensive intra-abdominal disease requiring evisceration. 26 isolated small bowel transplants were performed in the UK in 2014 [1]. With advances in surgical techniques and the evolution of immunosuppressants, notably monoclonal antibody therapy, small bowel transplantation is increasingly considered feasible in many patients with intestinal failure.

OC-032 Regenerative medicine for intestinal failure: demonstrating the potential for intestinal organoids to repopulate the epithelium of the intestine

<h3>Introduction</h3> Irreversible intestinal failure (IF) is associated with significant morbidity and mortality. Parenteral nutrition (PN) services have improved over the last decade, yet the life expectancy of patients on PN remains far below enterally fed patients.¹Patients suffering complications of PN are referred for intestinal transplantation however survival amongst those receiving a transplant is limited due to high graft-rejection rate, sepsis and risks of long-term immunosuppression. All these challenges reveal a persisting urgent need for new treatments for IF. Here, we present advances in our work on intestinal stem cell biology and tissue engineering that provide a realistic alternative to current available treatments for IF. <h3>Method</h3> Ethical approval was obtained from the NRES Committee London–Bloomsbury to collect intestinal tissue from patients at Great Ormond Street Hospital. Intestinal organoids were cultured as previously described.²Decellularization of whole intestinal sections was performed with 2 cycles of Detergent Enzymatic Treatment (DET).³Organoids were cultured on epithelial surfaces of acellular matrices <i><i>in vitro</i></i>for 10 days before fixation. Cell survival was analysed by histology, immunofluorescence and electron microscopy techniques. <h3>Results</h3> Three dimensional epithelial organoids were successfully cultured from endoscopic biopsies (Figure 1). Organoids were expanded to generate sufficient cells to repopulate the matrix at the required density. Whole sections of intestine were successfully decellularized and assessed using H&amp;E staining and scanning electron microscopy. Organoids were seeded onto the epithelial surface of the matrices and allowed to engraft for a period of 10 days. The formation of a neo-epithelium with evidence of a microvillus brush border was evident after 10 days in culture. Furthermore, cells had successfully migrated into the crypt domains of the matrix. <h3>Conclusion</h3> We demonstrate the potential of tissue engineering for intestinal failure by combining organoid cultures with decellularization expertise. Our results confirm intestinal organoids to be the ideal source of progenitor cells to regenerate the intestinal epithelium, with potential clinical applications for transplantation. <h3>Disclosure of interest</h3> None Declared. <h3>References</h3> Pironi L, Joly F, Forbes A, <i>et al</i>. Long-term follow up of patients on home parenteral nutrition in Europe: implications for intestinal transplantation. Gut 2011;60:17–25 Sato T, Stange DE, Ferrante M, <i>et al</i>. Long term expansion of epithelial organoids from human colon, adenoma, adenocarcinoma and Barrett’s epithelium. Gastroenterology 2011;141(5):1762–72 Totonelli G, Maghsoudlou P, Garriboli M, <i>et al</i>. A rat decellularized small bowel scaffold that preserves villus-crypt architecture for intestinal regeneration. Biomaterials 2012;33(12):3401–10

Cost-effectiveness of intestinal transplantation for adult patients with intestinal failure: a simulation study

Home parenteral nutrition (HPN) and intestinal transplantation (ITx) are the 2 treatment options for irreversible intestinal failure (IF). This study simulated the disease course of irreversible IF and both of these treatments--HPN and ITx--to estimate the cost-effectiveness of ITx. We simulated IF treatment in adults as a discrete event model with variables derived from the Dutch Registry of Intestinal Failure and Intestinal Transplantation, the Intestinal Transplant Registry, hospital records, the literature, and expert opinions. Simulated patients were enrolled at a rate of 40/mo for 10 y. The maximum follow-up was 40 y. Survival was simulated as a probabilistic function. ITx was offered to 10% of patients with <12 mo of remaining life expectancy with HPN if they did not undergo ITx. Costs were calculated according to Dutch guidelines, with discounting. We evaluated the cost-effectiveness of ITx by comparing models conducted with and without ITx and by calculating the cost difference per life-year gained [incremental cost-effectiveness ratio (ICER)]. The average survival was 14.6 y without ITx and 14.9 y with ITx. HPN costs were €13,276 for treatment introduction, followed by €77,652 annually. The costs of ITx were ∼€73,000 during the first year and then €13,000 annually. The ICER was €19,529 per life-year gained. Our simulations show that ITx slightly improves survival of patients with IF in comparison with HPN at an additional cost of €19,529 per life-year gained.

Short bowel: from resection to transplantation

Short bowel syndrome (SBS) is characterized by a significant reduction in the effective intestinal surface by an anatomical or functional loss of the small intestine. It mainly occurs after extensive bowel resection, intestinal intrinsic disease or surgical bypass. The main complications are malabsorption, maldigestion, malnutrition, dehydratation and, potentially, lethal metabolic lesions. The treatment is based on appropiate, individualized nutritional support; however, the most recent outcomes on bowel transplantation (BT) and a great rate of survivors achieving complete digestive autonomy and able to carry out activities according to their age allow for considering BT as the first choice therapy in patients with irreversible intestinal failure in whom poor prognosis with parenteral nutrition is foreseen. In this paper the most outstanding aspects of SBS are revised.

Quality of Life and Performance Status Before and After Small Intestinal Transplantation

IntroductionIntestinal transplantation (IT) is considered for patients with irreversible intestinal failure who develop life-threatening complications of parenteral nutrition or have extensive intra-abdominal disease requiring evisceration. Developing indications may include quality of life (QOL) considerations and therefore assessment of QOL and performance status (PS) after IT is important. We report QOL and PS before and after IT in our cohort. MethodsConsecutive patients undergoing IT were included. QOL was assessed using the generic 36-item short form survey (SF 36) tool at assessment and 6-month intervals post-transplantation. Performance was assessed using a visual analogue scale (VAS), Karnofsky scale (KS), and the Eastern Cooperative Oncology Group scale at three time points: premorbidly, at listing, and after transplantation. ResultsData were available for 21 patients. There were 11 complete SF 36 datasets and 15 performance scores. Data were not available from 3 patients, and the overall response rate was 62%. Overall, there was a trend for improved SF 36 scores post-transplantation in approximately half of the patients with scores remaining stable in approximately one third. The results of the SF 36 significantly improved in 1 patient (P < .01). After IT, 66% of patients had better VAS scores than at listing and >75% of patients scored better or the same in KS compared to status at listing. However, PS after IT did not improve to premorbid levels. ConclusionWe found a trend for QOL scores to improve in approximately half of the patients compared to their status at listing, remain static in approximately one third, and a minority experience a decline. For the majority, differences were not statistically significant. PS of patients after transplantation is equal or better than that at listing in 75%, but rarely reaches that of the premorbid status. Longer-term studies are needed and may reveal progressive improvement.

PTH-124 Changes In The Indications For Referral Of Adults For Intestinal And Multivisceral Transplantation

IntroductionSmall bowel transplantation (SBT) was first performed in the UK in Cambridge in 1991. Recipients mow undergo small bowel (SBT), liver and small bowel (LSBT), modified multivisceral (MMVT – small...

The application of polymerized porcine hemoglobin (pPolyHb) in the rat small bowel preservation

Small bowel transplantation (SBTx) has become a standard clinical treatment for short bowel syndrome or irreversible intestinal function failure. Optimum preservation of the organ is essential for the success of transplantation. In this study, pPolyHb was used as an additive to hypertonic citrate adenine solution (HCA) to provide oxygen for rat small bowel transplant. Rat small bowels were preserved in HCA, HCA with pPolyHb, and University of Wisconsin solution (UW) for 12, 24, and 36 h, respectively. The results suggested that the preservation effect of HCA with pPolyHb was comparable with the UW solution, and more effective than the HCA solution.