Living-related Small Bowel Transplantation Research Articles

Identical Twin Small-bowel Transplantation Without Maintenance Immunosuppression: A 5-year Follow-up and Literature Review.

BackgroundThe availability of an identical twin donor that allows avoidance of complications related to graft rejection and immunosuppression represents an ideal treatment option for irreversible intestinal failure.Methods and ResultsWe described a 45-year-old woman who lost most of her small bowel due to acute superior mesenteric thrombosis received a living-related small bowel transplant from her identical-twin sister. Monozygosity was established by buccal smear DNA amplification using short tandem repeat. A pretransplant panel-reactive antibody was 47.5% with several HLA antibodies in higher titers. The patient received a brief course of steroids without any additional immunosuppressive agents after transplantation. Her postoperative course was uneventful without an episode of rejection or infection. The preformed HLA antibodies steadily declined over time after transplantation. At a 5-year follow-up, the patient achieved full enteral autonomy from parenteral nutrition with a regular lifestyle.ConclusionsIdentical-twin intestinal transplantation appears to provide the best outcomes by avoiding complications related to rejection and immunosuppression. We provide evidence that it may confer greater long-term immunological advantages even in a high-immunologic risk recipient.

Living-Related Small Bowel Transplantation for Three Patients With Short Gut Syndrome

We summarized our experience of living-related small bowel transplantation and postoperative management of 3 patients with short gut syndrome. Patient #1, an 18-year-old boy, received a 150-cm segment of distal ileum with a vascular pedicle of distal superior mesenteric artery and vein, which was donated by his father. Patient #2, a 15-year-old boy, received a 160-cm graft of distal ileum from his mother. Patient #3, a 17-year-old boy, received a 170-cm graft of distal ileum from his father. The graft artery and vein were anastomosed to the recipient infrarenal aorta and vena cava, respectively, in end-to-side fashion using 7/0 Prolene suture. Intestinal continuity was restored by anastomosis of proximal end of the graft to the recipients' own proximal jejunum, the distal end was left open as a stoma. The recipient distal gut was anastomosed to the distal end of the graft. All 3 recipients were given FK506 (tacrolimus) regularly combined with periodic mycophenolate mofetil. In cases of acute rejection, large doses of steroids were administered to the recipients. The recipients and donors had fairly unremarkable postoperative courses. So far, patient #1 has survived for 7 years and 6 months with a well-functioning graft and without requirement for total parenteral nutrition (TPN) support. His body weight increased 20 kg and of his life quality has dramatically improved. Patient #2, however, died of acute rejection with fatal sepsis at 5 months after transplantation. Patient #3 has survived for 3 years and 8 months enjoying a normal life. Postoperative recovery of all 3 donors was unremarkable. They were discharged 12 days after surgery without complications. Outcomes of the implantation using the distal ileum as a graft in living-related small bowel transplantation have been satisfactory for both recipients and donors. It is feasible to anastomose the graft artery and vein to the recipient infrarenal aorta and vena cava. The intestinal continuity can be restored by a 1-stage strategy with minimal risk to the recipient. Appropriate application and adjustment of immune suppressors are crucial for the recipients to experience high-quality lives.

Vascular Anastomosis and Two-Stage Reconstruction of the Gut in a Living-Related Small Bowel Transplant Recipient: A Case Report

Aim We sought to discuss vascular anastomosis and gut reconstruction in a living-related small bowel transplantation recipient. Methods Living-related small bowel transplantation was performed successfully on a boy with short gut syndrome in two stages. In the first stage, 120 cm, of his mother’s ileum was implanted into the recipient with the artery and vein anastomosed to the recipient’s sigmoid artery and inferior mesenteric vein, respectively. The two ends of the implanted intestine were constructed as stomas. In the second stage, reconstruction of the continuity of the digestive tract was performed at 188 days after the initial transplantation. The residual small bowel was transected and both ends were anastomosed to the proximal and distal end of the graft in end-to-side fashion. The stomas were closed 30 and 43 days later. Results Both procedures were successful. Postoperative cytomegalovirus infection and acute rejection occurred successively and were controlled. No leakage of the reconstructed gut or other complications developed after the second procedure. The recipient is alive at 15 months with 8 kg an increase in weight. He is caring for himself independently and has a half-liquid diet, sometimes supplied with auxiliary enteral nutrition. A d-xylose test increased from 4.25% to 25% after the small bowel transplantation. Conclusions Vascular anastomoses should be performed according to the state of graft and the recipient. The portal route is the first choice when possible. A two-stage gut reconstruction could decrease the incidence of complications, and offer a useful method in living-related small bowel transplantation.

Two Cases of Living-Related Intestinal Transplantation

We recently performed living-related small bowel transplant in two patients. The first patient was a 14-year-old boy with total parenteral nutrition (TPN)-dependent short-bowel syndrome associated with hypoganglionosis. He received a bowel graft from his 43-year-old mother. The second patient was a 27-year-old female who had undergone massive enterectomy due to volvulus. She underwent living-related bowel transplantation from her 57-year-old mother. In both cases, blood types were ABO identical, cytotoxic cross matches were negative, and cytomegalovirus status was positive to positive in both cases. Up to one third of the donor bowel was harvested from the distal ileum. The graft vessels were connected to infrarenal aorta and inferior vena cava. The immunosuppressive regimen consisted of daclizumab, tacrolimus, and steroids. The first patient developed progressive acute cellular rejection on postoperative day 9, requiring OKT-3 therapy. Two months after transplantation, he was weaned off TPN, tolerating oral intake with a fully functioning graft. The second patient was weaned off TPN on day 29 with a functioning graft. Her metabolic disorder dramatically improved. This patient developed indeterminate acute cellular rejection on day 111, which was successfully treated with bolus injections of steroid. Both donors had no complications; they were discharged on day 10. Living-related intestinal transplantation can be a treatment option for patients with short-bowel syndrome.

Successful identical-twin living donor small bowel transplant for necrotizing enterovasculitis secondary to Churg-Strauss syndrome

Churg-Strauss syndrome (CSS) is a granulomatous small-vessel vasculitis with unknown etiology. Extra-pulmonary manifestations of CSS are currently treated with a combination of steroids and Cyclophosphamide. Its gastrointestinal complications may be devastating, occasionally requiring extensive bowel resection resulting in short-gut syndrome. Living-related small bowel transplantation (LRSBTx) is a relatively standardized procedure that, not only represents a valid alternative to cadaver bowel transplant in selected cases, but also portraits excellent results when performed in experienced centers. The availability of an identical twin as a donor, which allows avoidance of immunosuppressive therapy, is a major indication for this procedure. We present the case of a young individual affected by gastrointestinal necrotizing vasculitis that lost almost his entire small bowel requiring the immediate institution of total parenteral nutrition (TPN). However, within few weeks a significant hepatic dysfunction ensued. An identical twin-brother, not affected with CSS, became an immediate, optimal donor-candidate for LRSBTx, the first of this kind in a patient affected with CSS. Following the procedure, two main concerns were addressed: the recipient's ability to recover a regular intestinal function without immunosuppression and the possible recurrence of the primary disease. Twenty-seven months post-transplant, the patient enjoys a regular lifestyle without any clinical, endoscopic and histologic evidences of recurrent disease in the transplanted graft.

Innovative Approaches to Improving Organ Availability for Small Bowel Transplant Candidates

Small bowel transplant candidates have unique features that create special challenges for providing them with organs in a timely manner. More than half of intestinal transplant candidates also need livers. Because there is a greater overall demand for livers than for small bowels, organ allocation in this candidate subset is dictated by the liver allocation policies. However, the extremely high mortality rate associated with patients on the waiting list for combined liver-intestinal transplantation (LIT) attests to the inadequacies of the liver allocation system in recognizing the unique risk factors in patients with intestinal failure who develop end-stage liver disease (ESLD). This report addresses some of the organ allocation issues underlying the discrepancies in waiting list outcomes seen in LIT candidates and discusses possible contributory factors and potential solutions to this problem. The use of living donor and segmental grafts from deceased donors are discussed specifically as potential surgical solutions to the problem, and the potential utility, limitations, and ethical concerns associated with these innovative strategies are discussed.

Living-Related Small Bowel Transplantation: Two Cases Experiences

We have recently performed living-related small bowel transplantation for 2 patients. The first patient was a 14-year-old boy with total parenteral nutrition (TPN)–dependent short-bowel syndrome associated with hypoganglionosis of the entire intestine. He received a bowel graft from his 43-year-old mother. The second patient was a 27-year-old woman, who had massive enterectomy due to volvulus and developed vitamin deficiencies and severe metabolic disorders as a result of long-term TPN. She underwent living-related bowel transplantation from her 57-year-old mother. Blood types were ABO identical, cytotoxic cross matches were negative, and cytomegalovirus statuses were positive-to-positive in both cases. 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 graft vessels were connected to infrarenal aorta, and inferior vena cava. The immunosuppressive regimen consisted of daclizumab, tacrolimus, and steroid. The graft surveillance was accomplished using zoom endoscopy and mucosal biopsy. The first patient developed progressive acute cellular rejection (ACR) on the 9th postoperative day (POD)-9 requiring OKT-3 therapy, which was effective. Two months after transplantation, he was weaned from TPN, tolerating oral intake with a fully functioning graft. The second patient experienced no episode of ACR and was weaned off TPN on POD-29 with a functioning graft. Her metabolic disorder dramatically improved after bowel transplantation. Both donors had no complication and were discharged from the hospital on POD-10. Living-related bowel transplantation is an extreme option of treatment for patients with short-bowel syndrome.

Diagnosis and treatment of acute rejection in the first case of human living-related small bowel transplantation with a long-term survival in China

To report the comprehensive diagnosis and treatment of acute rejection in the first case of living-related small bowel transplantation with a long-term survival in China. A 18-year-old boy with short gut syndrome underwent living-related small bowel transplantation, with the graft taken from his father (44-year old). A segment of 150-cm distal small bowel was resected from the donor. The ileo-colic artery and vein from the donor were anastomosed to the infrarenal aorta and vena cava of the recipient respectively. The intestinal continuity was restored with an end-to-end anastomosis between the recipient jejunum and donor ileum, and the distal end was fistulized. FK506, MMF and prednisone were initially used for post-transplant immunosuppression. Endoscopic observation and mucosal biopsies of the graft were carried out through the terminal ileum enterostomy; serum was collected to detect the levels of IL-2R, IL-4, IL-6 and IL-8. The change of the graft secretion and absorption was observed. Acute rejection was diagnosed promptly and cured. The patient was in good health, 5 years after living-related small bowel transplantation. The correct diagnosis and treatment of acute rejection are the key to the long-term survival after living-related small bowel transplantation.

Renal Function in Rare Living Related Small Bowel Transplant Children.

BACKGROUND: Data from United Network for Organ Sharing (UNOS) and Organ Procurement and Transplantation Network (OPTN) reveals that living related small bowel transplant (LRSMT) in children, age less than 5 years, has been performed only 5 patients since 1988 - 2004. From these national data, 4/5 LRSMT were done at The University of Illinois Medical Center. In this study, we present renal function in this group of patients.

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

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.

Living-related small bowel transplantation

Living-related small bowel transplantation

Ileal absorptive adaptation to jejunal resection and extrinsic denervation: implications for living-related small bowel transplantation

Net absorption of water, electrolytes, and simple nutrients decreases early after jejunoileal autotransplantation (extrinsic denervation) in a canine model but recovers toward normal by 8 weeks. However, the ability of the extrinsically denervated ileum to adapt after total jejunectomy, which would be relevant as a model of segmental small bowel transplantation, remains unknown. Two groups of five dogs each were studied before and 2 weeks and 12 weeks after 50% proximal enterectomy. A control group remained neurally intact, whereas the other group underwent extrinsic denervation (Ext Den) of the remaining ileum. Using a perfusion technique, net absorption of water, electrolytes, and five simple nutrients (glucose, arginine, glutamine, and oleic and taurocholic acids) was measured at the three time points. Ileal morphometry was also evaluated. All dogs developed diarrhea, which resolved by 12 weeks in all but two of the Ext Den dogs. Weight in both groups was decreased at 2 weeks ( P <0.05), returned to normal at 12 weeks in control dogs, but remained low in Ext Den dogs ( P <0.05). Maximal weight loss was greater in the Ext Den group ( P <0.05). No consistent or important differences in net absorptive fluxes of water, electrolytes, or simple nutrients were noted either within or between groups at any time point. Villous height, crypt depth, and longitudinal muscle width increased significantly at 12 weeks after jejunectomy in the Ext Den dogs, but not in the control dogs ( P <0.05). Extrinsic denervation of the ileum results in persistent weight loss after proximal 50% enterectomy. Despite diarrhea, only minor changes in electrolyte absorption occur, and ileal net absorption of simple nutrients remains unaffected. The ileum of extrinsically denervated dogs undergoes a more prominent morphometric adaptation after jejunectomy. Extrinsic denervation necessitated by small bowel transplantation, independent of immune effects, does not appear to suppress the ileal adaptive response to maintain net absorption of water, electrolytes, and simple nutrients.

Infectious complications following living-related small bowel transplantation in adults

Infectious complications following living-related small bowel transplantation in adults

Living-related small bowel transplantation: two case reports

Living-related small bowel transplantation: two case reports

The living-related small bowel transplant: the first case in China

The living-related small bowel transplant: the first case in China

Small bowel transplantation using grafts from living-related donors. Two case reports

Abstract A living-related small bowel transplantation (SBT) was performed in two pediatric patients with short bowel syndrome. In both cases, the donor was the patient's mother. The distal ileum (100 cm, 120 cm) was harvested and the ileocolic vessels, ileocecal valve, and terminal ileum were left intact. The two donors were discharged from the hospital on postoperative days 15 and 6, respectively. Recipient 1 was a 2 year 6 month-old boy with short bowel syndrome who underwent SBT due to loss of venous access. The graft vein was anastomosed to the recipient's infrarenal inferior vena cava. Despite triple immunosuppression (tacrolimus, steroid, and azathioprine), there were four episodes of rejection. The patient had been on total parenteral nutrition for almost his entire post-transplant course. He died from Pneumocystis carinii pneumonia 16 months after the transplantation. Recipient 2 was a 4 year 5 month-old girl with short bowel syndrome who underwent an isolated small bowel transplantation because of recurrent line sepsis. Her pretransplant bilirubin was 8.0 mg/dl and a biopsy showed severe fibrosis. The graft vein was anastomosed to the recipient's inferior mesenteric vein. After transplantation, her bilirubin level became normal within 10 days. Triple immunosuppression (tacrolimus, steroid, and cyclophosphamide) together with a 3-day course of OKT-3 made her post-transplant course feasible. After overcoming a single episode of rejection she left the hospital 4 months after SBT. The patient is currently (10 months after transplantation) hospitalized due to rejection, which is being successfully controlled, and she is off total parenteral nutrition. From our experience, harvesting of the distal ileum for use as a bowel graft can be safely performed. The advantages of living-related grafts, optimal graft length, and choice of vascular reconstruction in SBT are yet to be explored.

Small bowel transplantation using grafts from living-related donors. Two case reports

A living-related small bowel transplantation (SBT) was performed in two pediatric patients with short bowel syndrome. In both cases, the donor was the patient's mother. The distal ileum (100 cm, 120 cm) was harvested and the ileocolic vessels, ileocecal valve, and terminal ileum were left intact. The two donors were discharged from the hospital on postoperative days 15 and 6, respectively. Recipient 1 was a 2 year 6 month-old boy with short bowel syndrome who underwent SBT due to loss of venous access. The graft vein was anastomosed to the recipient's infrarenal inferior vena cava. Despite triple immunosuppression (tacrolimus, steroid, and azathioprine), there were four episodes of rejection. The patient had been on total parenteral nutrition for almost his entire posttransplant course. He died from Pneumocystis carinii pneumonia 16 months after the transplantation. Recipient 2 was a 4 year 5 month-old girl with short bowel syndrome who underwent an isolated small bowel transplantation because of recurrent line sepsis. Her pretransplant bilirubin was 8.0 mg/dl and a biopsy showed severe fibrosis. The graft vein was anastomosed to the recipient's inferior mesenteric vein. After transplantation, her bilirubin level became normal within 10 days. Triple immunosuppression (tacrolimus, steroid, and cyclophosphamide) together with a 3-day course of OKT-3 made her post-transplant course feasible. After overcoming a single episode of rejection she left the hospital 4 months after SBT. The patient is currently (10 months after transplantation) hospitalized due to rejection, which is being successfully controlled, and she is off total parenteral nutrition. From our experience, harvesting of the distal ileum for use as a bowel graft can be safely performed. The advantages of living-related grafts, optimal graft length, and choice of vascular reconstruction in SBT are yet to be explored.

Living-Related Small Bowel Transplant: Management of Rejection and Infection

Living-Related Small Bowel Transplant: Management of Rejection and Infection

Living related small bowel transplantation: Anaesthesia and peri-operative care

The peri-operative management of the only surviving case, to date, of living-related small bowel transplantation is described. The anaesthetic technique was chosen to optimize hepato-splanchnic blood flow. Peri-operative splanchnic blood flow was measured and alterations in flow with changes in inotropic agents and volume loading monitored. There appears to be a role for the use of dopexamine and aggressive volume loading.

Living-related small bowel transplantation in adults: A report of two patients

Virtually all of the small bowel transplants performed to date have utilized the whole intestine harvested from cadaveric donors. There may be distinct potential advantages to the transplantation of segments of small intestine. Experimentally, segments undergo adaptive hyperplasia, resulting in deeper crypts and taller villi. The increased mucosal surface area augments intestinal absorption and restores function in enterectomized animals. There is a direct relationship between the mass (length) of the graft and its immunogenicity in small animals, with longer segments rejecting more rapidly and mandating the use of higher doses of immunosuppression. Also, there is substantial immunologic advantage to the use of jejunum, rather than ileum in rats, although bowel from both sites otherwise function equally well. Finally, transplantation of segments would solve the problem of availability of intestine, and might overcome size restrictions, perhaps even permitting the use of adult donors for pediatric recipients. Based on these observations, and the potential advantage afforded by immediate revascularization, we initiated a program of living-related small intestinal transplantation in adults.