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Cost-effectiveness of Intestinal Transplantation Compared to Parenteral Nutrition in Adults. Transplantation 2021; 105:897-904. [PMID: 32453254 DOI: 10.1097/tp.0000000000003328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Intestinal transplantation (ITx) is the most expensive abdominal organ transplant. Detailed studies about exact costs and cost-effectiveness compared to home parenteral nutrition (HPN) therapy in chronic intestinal failure are lacking. The aim is to provide an in-depth analysis of ITx costs and evaluate cost-effectiveness compared to HPN. METHODS To calculate costs before and after ITx, costs were analyzed in 12 adult patients. To calculate the costs of patients with uncomplicated chronic intestinal failure, 28 adults, stable HPN patients were studied. Total costs including surgery, admissions, diagnostics, HPN therapy, medication, and ambulatory care were included. Median (range) costs are given. RESULTS Costs before ITx were €69 160 (€60 682-90 891) in year 2, and €104 146 (€83 854-186 412) in year 1. After ITx, costs were €172 133 (€122 483-351 407) in the 1st year, €40 619 (€3905-113 154) in the 2nd year, and dropped to €15 743 (€4408-138 906) in the 3rd year. In stable HPN patients, the costs were €83 402 (€35 364-169 146) in the 1st year, €70 945 (€31 955-117 913) in the 2nd year, and stabilized to €60 242 (€29 161-238 136) in the 3rd year. CONCLUSIONS ITx, although initially very expensive, is cost-effective compared to HPN in adults by year 4, and cost-saving by year 5.
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Andersen DA, Horslen S. An Analysis of the Long-Term Complications of Intestine Transplant Recipients. Prog Transplant 2016; 14:277-82. [PMID: 15663012 DOI: 10.1177/152692480401400402] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background One-year survival rates for intestine transplant recipients have increased to 70%, but it is believed that the complications following the procedure do not diminish after the first year as is seen in other forms of solid-organ transplantation. Objective To review the ongoing medical requirements of an increasing number of long-term survivors of intestinal transplantation. Method A retrospective medical chart review was completed on all patients who received intestinal transplantation at the University of Nebraska Medical Center from September 1990 through March 2003. One hundred forty-six transplantations were performed on 128 patients—53 intestinal, 70 liver/intestinal, and 23 intestinal with liver and pancreas or kidney. Results Seventy-six patients survived longer than 365 days and form the study group. Major reasons for readmissions were infections, gastrointestinal complications, dehydration, and rejection. The average number of rehospitalizations per patient per year remained constant. Death in patients with more than 365 days survival (N=23) was the result of sepsis (56%) and multiple other complications (44%). Conclusion The number of readmissions each year per patient remains constant and medical problems remain complex and life threatening. Patients with intestinal transplantation will continue to require regular expert follow-up care and careful attention to even the smallest medical problem even years following transplantation.
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Abstract
As technology introduces more advanced therapies, individuals have realized that quantity or length of life may not always be the ultimate goal in treating disease. The quality of life at times is as important as length of life. In this article, we review the literature regarding quality of life after intestinal transplantation. Published data on patient survival are briefly reviewed and the available studies investigating quality of life are examined. Few studies have been performed to date, but the limitations and implications of the available studies are summarized.
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Affiliation(s)
- Debra Sudan
- University of Nebraska Medical Center, Omaha, Neb., USA
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Andres AM, Santamaria M, Hernandez-Oliveros F, Guerra L, Lopez S, Stringa P, Vallejo MT, Largo C, Encinas JL, Garcia de Las Heras MS, Lopez-Santamaria M, Tovar JA. Difficulties, guidelines and review of developing an acute rejection model after rat intestinal transplantation. Transpl Immunol 2016; 36:32-41. [PMID: 27102447 DOI: 10.1016/j.trim.2016.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 04/12/2016] [Accepted: 04/15/2016] [Indexed: 02/07/2023]
Abstract
Experimental small bowel transplantation (SBT) in rats has been proven to be a useful tool for the study of ischemia-reperfusion and immunological aspects related to solid organ transplantation. However, the model is not completely refined, specialized literature is scarce and complex technical details are typically omitted or confusing. Most studies related to acute rejection (AR) use the orthotopic standard, with small sample sizes due to its high mortality, whereas those studying chronic rejection (CR) use the heterotopic standard, which allows longer term survival but does not exactly reflect the human clinical scenario. Various animal strains have been used, and the type of rejection and the timing of its analysis differ among authors. The double purpose of this study was to develop an improved unusual AR model of SBT using the heterotopic technique, and to elaborate a guide useful to implement experimental models for studying AR. We analyzed the model's technical details and expected difficulties in overcoming the learning curve for such a complex microsurgical model, identifying the potential problem areas and providing a step-by-step protocol and reference guide for future surgeons interested in the topic. We also discuss the historic and more recent options in the literature.
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Affiliation(s)
- Ane Miren Andres
- Pediatric Surgery Department, La Paz University Hospital, Paseo La Castellana, 261, 28046 Madrid, Spain.
| | - Monica Santamaria
- Experimental Surgery Department, La Paz University Hospital, Paseo La Castellana, 261, 28046 Madrid, Spain.
| | | | - Laura Guerra
- Pathology Department, La Paz University Hospital, Paseo La Castellana, 261, 28046 Madrid, Spain.
| | - Sergio Lopez
- Pediatric Surgery Department, La Paz University Hospital, Paseo La Castellana, 261, 28046 Madrid, Spain.
| | - Pablo Stringa
- Fundacion Favaloro Buenos Aire:Experimental Transplant Department, Buenos Aires, Argentina.
| | - Maria Teresa Vallejo
- Idipaz Institute, Immunohistochemistry Department, Paseo La Castellana, 261, 28046 Madrid, Spain.
| | - Carlota Largo
- Experimental Surgery Department, La Paz University Hospital, Paseo La Castellana, 261, 28046 Madrid, Spain.
| | - Jose Luis Encinas
- Pediatric Surgery Department, La Paz University Hospital, Paseo La Castellana, 261, 28046 Madrid, Spain.
| | | | - Manuel Lopez-Santamaria
- Pediatric Surgery Department, La Paz University Hospital, Paseo La Castellana, 261, 28046 Madrid, Spain.
| | - Juan Antonio Tovar
- Pediatric Surgery Department, La Paz University Hospital, Paseo La Castellana, 261, 28046 Madrid, Spain.
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Abstract
Intestinal transplantation is the definitive therapy for patients with irreversible intestinal failure and can be combined with transplantation of other abdominal organs, such as stomach, spleen, and pancreas with or without liver. There is an increasing trend in the volume of intestinal and multivisceral transplantation in the past few decades and there is also increasing trend in patient and graft survival primarily due to improved patient selection, advances in immunosuppression, and improved perioperative management. This review summarizes the various key elements in patient selection, types of grafts, and updates in the perioperative management involved in multivisceral transplantation.
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Affiliation(s)
- Kalyan Ram Bhamidimarri
- Miami Transplant Institute, University of Miami, 1500 Northwest 12th Avenue, Suite 1101, Miami, FL 33136, USA
| | - Thiago Beduschi
- Miami Transplant Institute, University of Miami, Highland Professional Building, 1801 Northwest 9th Avenue, Suite 310, Miami, FL 33136, USA
| | - Rodrigo Vianna
- Miami Transplant Institute, University of Miami, Highland Professional Building, 1801 Northwest 9th Avenue, Suite 310, Miami, FL 33136, USA.
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Mercer DF, Iverson AK, Culwell KA. Nutrition and Small Bowel Transplantation. Nutr Clin Pract 2014; 29:615-20. [DOI: 10.1177/0884533614539354] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- David F. Mercer
- Division of Transplantation, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Angie K. Iverson
- Department of Pharmaceutical and Nutrition Care, Nebraska Medical Center, Omaha, Nebraska
| | - Karley A. Culwell
- Department of Pharmaceutical and Nutrition Care, Nebraska Medical Center, Omaha, Nebraska
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7
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Florescu DF, Langnas AN, Sandkovsky U. Opportunistic viral infections in intestinal transplantation. Expert Rev Anti Infect Ther 2014; 11:367-81. [DOI: 10.1586/eri.13.25] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Akhter K, Timpone J, Matsumoto C, Fishbein T, Kaufman S, Kumar P. Six-month incidence of bloodstream infections in intestinal transplant patients. Transpl Infect Dis 2011; 14:242-7. [PMID: 22093913 DOI: 10.1111/j.1399-3062.2011.00683.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Revised: 07/19/2011] [Accepted: 08/13/2011] [Indexed: 01/29/2023]
Abstract
BACKGROUND Intestinal transplantation has emerged as an established treatment for life-threatening intestinal failure. The most common complication and cause of death is infection. Risk of infection is highest during the first 6 months, as a consequence of maximal immunosuppression, greater than that required for any other organ allograft. METHODS We performed a retrospective chart review of all (56) adult and pediatric (<18 years) small bowel transplant patients at our institution between November 2003 and July 2007, and analyzed the 6-month post-transplant incidence of bloodstream infections (BSIs). We evaluated multiple risk factors, including inclusion of a colon or liver, total bilirubin >5, surgical complications, and acute rejection. RESULTS A BSI developed in 34 of the 56 patients, with a total of 85 BSI episodes. Of these BSI episodes, 65.9% were due to gram-positive organisms, 34.1% gram-negative organisms, and 2.4% due to fungi. The most common isolates were Enterococcus species, Enterobacter species, Klebsiella species, and coagulase-negative staphylococci. Inclusion of the liver and/or a preoperative bilirubin >5 mg/dL appeared to increase the incidence of BSI (P = 0.0483 and 0.0005, respectively). Acute rejection and colonic inclusion did not appear to affect the incidence of BSI (P = 0.9419 and 0.8248, respectively). The BSI incidence was higher in children (P = 0.0058). CONCLUSIONS BSIs are a common complication of intestinal transplantation. Risk factors include age <18, inclusion of the liver, and pre-transplant bilirubin >5. Acute rejection and colon inclusion do not appear to be associated with increased BSI risk.
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Affiliation(s)
- K Akhter
- Infectious Diseases Faculty Practice, Orlando Health, Orlando, Florida 32806, USA.
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Pretransplant predictors of survival after intestinal transplantation: analysis of a single-center experience of more than 100 transplants. Transplantation 2011; 90:1574-80. [PMID: 21107306 DOI: 10.1097/tp.0b013e31820000a1] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Outcomes after intestinal transplantation (ITx) have steadily improved. There are few studies that assess factors associated with these enhanced results. The purpose of this study was to examine peri-ITx variables and survival. METHODS A review of a prospectively maintained database was undertaken and included all patients undergoing ITx from 1991 to 2010. The study endpoints were patient and graft survival. Data collection included 44 variables. Survival was computed using Kaplan-Meier methods. Univariate analysis was conducted (log-rank test) with significance set at P less than or equal to 0.20. Multivariate analysis of significant variables was conducted using model reduction by backward elimination variable selection method with significance set at P less than 0.05. RESULTS Eighty-eight patients received 106 ITx. The majority of recipients were male, Latino, and children. The leading causes of intestinal and liver failure were gastroschisis and parenteral nutrition. Grafts transplanted were isolated intestine (24%), liver-intestine (62%), and multivisceral (14%). Overall 1- and 5-year patient and graft survival were 80% and 65%, and 74% and 64%, respectively. Significant univariate survival predictors were weight less than 20 kg, children, liver-inclusive allograft, panel reactive antibody less than 20%, absence of donor-specific antibody, negative crossmatch, warm ischemia time less than 60 min, absence of recipient splenectomy, interleukin-2 receptor antagonist induction, and era. Significant multivariate survival predictors were absence of donor-specific antibody, absence of recipient splenectomy, and liver-inclusive graft type. CONCLUSION This large, single-center ITx experience confirms a marked improvement in outcome over time. Several important factors were associated with survival, and these factors can potentially be adjusted before ITx. These findings should refocus future efforts on strategies to improve treatment and prevent graft loss.
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Abstract
Diseases of the gastrointestinal system frequently complicate immunosuppressed patients. Endogenous flora is the principal source of infection in humans, especially in patients with dysfunction of the digestive epithelial barrier due to various factors. Bacterial translocation, traumatisms, ischemia and surgery are frequent events in the general population. In addition, important risk factors for abdominal infections in specific patients include tumoral infiltration, mucositis complicating chemotherapy and/or radiotherapy, hypoproteinemia, neutropenia and lymphocyte deficiency. Clinical pictures vary according to patients' baseline condition and the environmental setting, including nosocomial infections. The differential clinical characteristics of abdominal infections observed in distinct types of immunosuppressed patients are reviewed.
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Andres AM, Santamaría ML, Ramos E, Sarriá J, Molina M, Hernandez F, Encinas JL, Larrauri J, Prieto G, Tovar JA. Graft-vs-host disease after small bowel transplantation in children. J Pediatr Surg 2010; 45:330-6; discussion 336. [PMID: 20152346 DOI: 10.1016/j.jpedsurg.2009.10.071] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Accepted: 10/27/2009] [Indexed: 12/26/2022]
Abstract
PURPOSE Graft-vs-host disease (GVHD) is a rare complication of transplantation of organs rich in immunocompetent cells. The goal of this study was to report the features of GVHD after small bowel transplantation (SBTx) in children. METHODS The study involved a retrospective review of patients undergoing SBTx between 1999 and 2009 who had GVHD. RESULTS Of 46 children receiving 52 intestinal grafts (2 liver-intestine and 3 multivisceral), 5 (10%) developed GVHD. Median age at transplant was 42 (19-204) months. Baseline immunosupression consisted of tacrolimus and steroids supplemented with thymoglobulin (n = 2) or basiliximab (n = 3) for induction. Median time between transplantation and GVHD was 47 (16-333) days. All patients had generalized rash, 2 had diarrhea, and 2 had respiratory symptoms. Other symptoms were glomerulonephritis (n = 1) and conjunctivitis (n = 1). Four developed severe hematologic disorders. The diagnosis was confirmed by skin biopsy in 4 patients and supported by chimerism studies in two. Colonoscopy and opthalmoscopic findings were also suggestive in one. Treatment consisted of steroids and decrease of tacrolimus, with partial response in four. Other immunosuppressants were used in refractory or recurrent cases. Three patients died within 4 months after diagnosis. CONCLUSION Graft-vs-host disease is a devastating complication of SBTx, with high mortality probably associated with severe immunologic dysregulation.
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Affiliation(s)
- Ane M Andres
- Department of Pediatric Surgery, Hospital Universitario La Paz, Paseo de Castellana 261, 28046 Madrid, Spain.
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Vianna RM, Mangus RS, Tector AJ. Current status of small bowel and multivisceral transplantation. Adv Surg 2008; 42:129-50. [PMID: 18953814 DOI: 10.1016/j.yasu.2008.03.008] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Intestinal transplantation has shown exceptional growth over the past 20 years with remarkable progress. As with other solid organ transplants, intestinal transplantation has moved out of the experimental realm to become the stan dard of care for many patients with intestinal failure. Intestinal transplantation may soon be extended routinely to patients who, although not strictly meeting the criteria for intestinal failure, may benefit from intestinal transplantation, such as patients who have nonresectable indolent tumors or diffuse thrombosis of the portomesenteric system. As clinical experience has increased with intestinal transplantation, outcomes have improved. The currently reported 1-year graft and patient survival rate is 80%, which approaches that for other solid abdominal organs. Unfortunately, most of the gains in survival are seen in the first postoperative year, with long-term survival remaining basically unchanged since the early 1990s. With improved outcomes, more centers have entered into the intestinal transplant arena. In the United States alone, 20 centers performed at least one intestinal transplant in 2007. Increase in access to intestinal transplantation and more widespread awareness of this option likely will result in a consistent increase in the number of yearly transplants for the foreseeable future. Immunosuppressive regimens continue to evolve, with induction therapy being the major change in the past 5 years. Although rejection rates in the first year after transplant have been reduced by induction therapy, long-term side effects of heavy immunosuppression continue to weigh negatively on transplant outcomes. The future for immunosuppression lies in two areas: (1) individual monitoring of the immunosuppression level for each individual patient and (2) development of serum and tissue markers for the early identification of rejection. It is likely that a combination of technologies will allow immunosuppression to be tailored to each recipient. Development of these approaches to immunosuppression is necessary to predict graft dysfunction ahead of irreversible graft injury and allows adjustments in immunosuppression before the onset of rejection. Intestinal transplantation continues to be performed only in situations in which all other therapeutic modalities have failed. No randomized trials compare intestinal transplantation to long-term PN to establish guidelines for a timely referral for this treatment option. Late referral remains a crippling problem in the field of intestinal transplantation, with a great number of patients in need of simultaneous liver transplantation at the time of listing for intestinal transplantation. Early referral for isolated intestinal transplant will reduce the need for simultaneous multiorgan transplants and increase the residual organs available for patients in need of (primarily) liver transplantation.
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Affiliation(s)
- Rodrigo M Vianna
- Intestinal and Multivisceral Transplantation, Transplant Surgery Section, Indiana University School of Medicine, Indiana University Hospital 4601, 550 N. University Blvd., Indianapolis, IN 46202, USA.
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Induction immunosuppression with thymoglobulin and rituximab in intestinal and multivisceral transplantation. Transplantation 2008; 85:1290-3. [PMID: 18475186 DOI: 10.1097/tp.0b013e31816dd450] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Induction immunosuppression is now a common practice after intestinal and multivisceral transplantation. We report our experience in 27 adult recipients who received rituximab and rabbit antithymocyte globulin (rATG) in combination as induction agents. MATERIAL AND METHODS Twenty-seven adult patients received 29 intestinal transplants between July 2004 and March 2007. All patients received induction immunosuppression therapy with rATG, rituximab, and steroids. Tacrolimums and a steroid taper were used for maintenance therapy. Patient and graft survival, episodes of rejection as well as posttransplant lymphoproliferative disease (PTLD) and graft-versus-host disease were analyzed. RESULTS One-year patient and graft survival was 81% and 76%, respectively. Thirteen patients (48%) experienced 19 episodes of acute rejection (9 mild episodes, 2 moderate, and 8 severe). Patients with a multivisceral graft experienced less episodes of severe acute rejection (1 of 19, 5%) when compared with isolated intestinal transplants and modified multivisceral transplants (7 of 10, 70%). Two patients had episodes of skin graft-versus-host disease that responded to steroid boluses. PTLD was not seen in our series. Two patients developed cytomegalovirus enteritis. CONCLUSIONS The combination of rATG and rituximab was an effective induction therapy in our preliminary data. The number and severity of rejection episodes increased when the liver was not included as part of the graft. An immunosuppression regimen including rATG, rituximab, and steroids may have a protective effect against PTLD and chronic rejection.
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Transplantation of the Intestine. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sudan DL. Treatment of intestinal failure: intestinal transplantation. ACTA ACUST UNITED AC 2007; 4:503-10. [PMID: 17768395 DOI: 10.1038/ncpgasthep0901] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2007] [Accepted: 07/02/2007] [Indexed: 01/18/2023]
Abstract
Over the past 15 years, intestinal transplantation for the treatment of intestinal failure has changed from a desperate last-ditch effort into a standard therapy for which a good outcome is expected. Patient survival after intestinal transplantation has improved in the past 3-5 years and now approaches that of other solid organ allograft recipients, including liver and kidney, and is similar to survival on permanent therapy with parenteral nutrition. Complications are more common and often more severe during the initial hospitalization period after intestinal transplantation than they are after transplantation of other solid organs. After intestinal transplantation the initial hospitalization period is, therefore, usually 3-8 weeks long. Nearly all patients discharged after intestinal transplantation have good allograft function and have been weaned from total parenteral nutrition. The cost of the initial hospitalization period is one to two times the cost of permanent total parenteral nutrition for 1 year, which means that, in most cases, intestinal transplantation is cost-saving within 2 years of transplantation. In addition, quality of life after intestinal transplantation, as determined by standardized quality of life measures, is good or normal.
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Affiliation(s)
- Debra L Sudan
- University of Nebraska Medical Center, Omaha, NE, USA.
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Zhao Y, Lu S, Cheng F, Shen LZ, Hua YB, Wu WX. The establishment of a new en bloc combined liver-small bowel transplantation model in rats. Transplant Proc 2007; 39:278-80. [PMID: 17275521 DOI: 10.1016/j.transproceed.2006.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2006] [Indexed: 11/16/2022]
Abstract
In order to facilitate preclinical research, we established a new combined liver-small bowel transplantation rat model. Male inbred Wistar rats were chosen as donors and recipients. An en bloc liver-small bowel graft was harvested. During the donor operation, the inferior vena cava in the chest was removed to be used as an interpositional venous graft to anastomose to the portal vein. In the recipient operation the portal veins of donor and recipient were quickly anastomosed using a cuff technique instead of the traditional suture method. Rearterialization was achieved by anastomosing the superior mesenteric artery of graft to the right renal artery of the recipient. The recipient small bowel was resected and intestinal continuity restored simultaneously by two end-to-end anastomoses. The postoperative 5-day survival rate was 77.5% (31/40) and 60-day survival rate, 72.5% (29/40). Recipient rats that tolerated the operation remained healthy. Liver and renal function was normal. The liver and intestinal grafts showed normal histological architecture in all rats surviving for 2 months postoperatively. Our results demonstrated that the present model is feasible, allowing preclinical experimental research on combined liver-small bowel transplantation.
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Affiliation(s)
- Y Zhao
- Gastrointestinal Surgery Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Longworth L, Young T, Beath SV, Kelly DA, Mistry H, Protheroe SM, Ratcliffe J, Buxton MJ. An Economic Evaluation of Pediatric Small Bowel Transplantation in the United Kingdom. Transplantation 2006; 82:508-15. [PMID: 16926595 DOI: 10.1097/01.tp.0000229438.14914.82] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Small bowel transplantation (SBTx) offers an alternative to parenteral nutrition (PN) for the treatment of chronic intestinal failure in children: this study estimated its cost-effectiveness in the early phase of a U.K. program. METHODS Children assessed for SBTx were categorized as: 1) requiring SBTx following PN-related complications (n=23), 2) stable at home not requiring SBTx (n=24), and 3) terminally ill and unsuitable for SBTx (n=6). Costs were estimated from detailed resource-use data. Two comparisons were used for effectiveness: actual survival following transplantation (n=14) compared to: 1) estimated survival without transplantation using a prognostic model, and 2) the waiting list experiences of all patients listed for SBTx (n=23). RESULTS Mean costs up to 30 months were pounds sterling 207,000 for those transplanted or on the waiting list, pounds sterling 159,000 for those stable on home PN, and pounds sterling 56,000 for those terminally ill. The prognostic model estimated a mean survival gain from transplantation of 0.12 years over 30 months, and suggested that transplantation was cost-saving. The second approach suggested that transplantation reduced survival by 0.24 years at an additional cost of pounds sterling 131,000. CONCLUSIONS Firm conclusions on cost-effectiveness of SBTx are not possible given the two different estimates. The prognostic model approach (suggesting that pediatric SBTx may provide a small survival benefit at a small reduction in costs) should be less subject to bias, but the model requires external validation. Meanwhile, children at risk of fatal PN-complications should be given the opportunity to receive a SBTx only within a continuing formal assessment of the technology.
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Affiliation(s)
- Louise Longworth
- Health Economics Research Group, Brunel University, Uxbridge, Middlesex, United Kingdom
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Dijkstra G, Rings EHHM, Bijleveld CMA, Van Dullemen HM, Hofker HS, Porte RJ, Ploeg RJ. Intestinal transplantation in The Netherlands: first experience and future perspectives. Scand J Gastroenterol 2006:39-45. [PMID: 16782621 DOI: 10.1080/00365520600664243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
Intestinal transplantation for intestinal failure is no longer an experimental procedure, but an accepted treatment for patients who fail total parenteral nutrition (TPN) therapy. Early referral for evaluation for small bowel transplantation has to be considered in patients with permanent intestinal failure who have occlusion of more than two major veins, frequent line-related septic episodes, impairment of liver function or an unacceptable quality of life. With the increased experience in post-transplant patient care and newer forms of induction (thymoglobulin, IL-2 receptor antagonists) and maintenance (tacrolimus) therapies the 1-year graft survival has increased to 65% for isolated and to 59% for liver/small bowel transplantation, and is further improving. Rejection, bacterial, fungal and viral (CMV, EBV) infection, post-transplant lymphoproliferative disease (PTLD) and graft versus host disease (GvHD) are the most common complications after intestinal transplantation. Although most of the long-term survivors are TPN-independent and have a good quality of life, the risk of the procedure and long-term adverse effects of immunosuppressive medication limits small bowel, or liver/small bowel transplantation only to patients with severe complications of TPN therapy.
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Affiliation(s)
- G Dijkstra
- Department of Gastroenterology and Hepatology, Groningen University Medical Centre, Groningen, The Netherlands.
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22
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Zou Y, Hernandez F, Burgos E, Martinez L, Gonzalez-Reyes S, Fernandez-Dumont V, Lopez G, Romero M, Lopez-Santamaria M, Tovar JA. Organ Changes and Bacterial Translocation in a Rat Model of Chronic Rejection After Small Bowel Transplantation. Transplant Proc 2006; 38:1569-72. [PMID: 16797359 DOI: 10.1016/j.transproceed.2006.03.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2005] [Indexed: 11/26/2022]
Abstract
UNLABELLED Rejection after small bowel transplantation (SBTx) may allow bacterial translocation damaging the liver and lungs. This study investigated these issues in a rat model of chronic rejection. MATERIALS AND METHODS Orthotopic SBTx was performed in syngeneic (SYN) (ACI-ACI, n=8) and allogeneic (ALLO) (ACI-Lewis, n=8) rat strain combinations. Cyclosporine was given to ALLO rats for 28 days. Animals were sacrified between 55 and 65 days. Lymph nodes and venous samples were cultured; Escherichia coli DNA was assessed by polymerase chain reaction. We measured intestine, liver, spleen, and lung protein and DNA contents. Chronic rejection was histologically confirmed. RESULTS Two of eight and four of eight rats died in the first week after SYN and ALLO SBTx, respectively. There were no differences in organ weights or DNA and protein contents compared with the controls. Gram-negative enteric bacteria were found in two of four ALLO and two of six SYN rats (ns), and aerobic gram-positive were found in two of four and two of six (ns), respectively. Anaerobic growth occurred in mesenteric lymph nodes in only one ALLO rat. E. coli DNA was negative in all animals. Lungs were severely emphysematous in ALLO rats with no histologic changes observed in the other phagocytic organs. Mild rejection was found in the intestine of ALLO rats. CONCLUSIONS Bowel lesions in ALLO rats might be consistent with chronic rejection and lung lesions could be related to bacterial translocation after SBTx. However, contrary to our expectations, no significant bacterial translocation was demonstrated in either group at the end of the experiments.
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Affiliation(s)
- Y Zou
- Department of Pediatric Surgery, Hospital Universitario, La Paz, Madrid, Spain
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23
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John M, Gondolesi G, Herold BC, Kaufman S, Fishbein T, Posada R. Impact of surveillance stool culture guided selection of antibiotics in the management of pediatric small bowel transplant recipients. Pediatr Transplant 2006; 10:198-204. [PMID: 16573607 DOI: 10.1111/j.1399-3046.2005.00424.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Surveillance stool cultures (SSC) have been used in immunocompromised populations to predict the organisms associated with invasive infections and aid in the selection of empiric antibiotic regimens. To evaluate the utility of this approach in pediatric small bowel transplant (SBT) recipients, we conducted a retrospective review of 33 patients who underwent SBT, 16 of whom had SSC done. In no case was the same organism isolated from SSC and subsequent blood, peritoneal fluid or wound cultures. In the first month post-transplantation, blood cultures were positive in 44% and 35% of patients that had and did not have SSC done, respectively (p = 0.73); peritoneal fluid cultures in 44% and 65% (p = 0.30); and wound cultures in 44% and 24% (p = 0.28). There were no significant differences among both groups in time to first infection, duration of ICU stay following SBT, graft survival or long-term patient survival. We conclude that SSC-guided antibiotic selection does not have a significant impact on the incidence of invasive infections in the first month following SBT or on specific indicators of patient outcome. This suggests that empiric antibiotic regimens should be selected based on clinical presentation and hospital flora and susceptibility patterns.
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Affiliation(s)
- Minnie John
- Department of Pediatrics, The Mount Sinai School of Medicine, New York, NY 10029, USA
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24
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Guaraldi G, Cocchi S, Codeluppi M, Di Benedetto F, De Ruvo N, Masetti M, Venturelli C, Pecorari M, Pinna AD, Esposito R. Outcome, Incidence, and Timing of Infectious Complications in Small Bowel and Multivisceral Organ Transplantation Patients. Transplantation 2005; 80:1742-8. [PMID: 16378070 DOI: 10.1097/01.tp.0000185622.91708.57] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Infectious complications still represent a major cause of morbidity and mortality in patients with organ transplantation. In particular, small bowel or multivisceral transplantation is complicated to a greater extent than other grafts as a consequence of infectious complications including sepsis. METHODS This prospective study assessed outcome, incidence, and timing of infections in sequential patients undergoing small bowel or multivisceral transplantation (SB/MVTx) performed at a university transplant center between January 2001 and October 2003. Nineteen patients underwent transplantation during this period, 13 of whom (68%) undergoing isolated SB and 6 (32%) MV grafts with or without liver. RESULTS The median follow up was 524 days (interquartile range=252-730) with an overall 24.4 person/year of observation. Postoperative mortality rate was 0.1 death/person/year; all patients, except one who died intraoperatively, were alive 6 months postsurgery. There were 100 documented infections including: 59 bacterial (2.4 events/person/year), 35 viral (1.4 events/person/year) and 6 fungal (0.2 events/person/year). Patients developed at least one episode of bacterial infection in 94% of the cases, viral infection in 67%, and fungal infection in 28%. CONCLUSIONS This cohort describes the very common and complex nature of infectious complications in this challenging group of transplantation patients. Larger cohorts are needed to specifically address infection risk factors and longer term outcomes.
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Affiliation(s)
- Giovanni Guaraldi
- Department of Medicine and Medical Specialities, Infectious Diseases Clinic, University of Modena and Reggio Emilia, Modena, Italy.
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25
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Di Benedetto F, Lauro A, Masetti M, Cautero N, De Ruvo N, Quintini C, Diago Uso' T, Romano A, Dazzi A, Ramacciato G, Cipriani R, Ercolani G, Grazi GL, Gerunda GE, Pinna AD. Use of prosthetic mesh in difficult abdominal wall closure after small bowel transplantation in adults. Transplant Proc 2005; 37:2272-4. [PMID: 15964397 DOI: 10.1016/j.transproceed.2005.03.062] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2005] [Indexed: 12/28/2022]
Abstract
Abdominal wall closure after intestinal transplantation in adult patients can be a difficult procedure. The main possibility offered by international experience is the use of myocutaneous flaps and abdominal wall transplantation. We report our experience in intestinal/multivisceral transplantation, including four difficult cases among 27 adult transplant recipients. Three patients underwent prosthetic mesh alone and one, a myocutaneous flap for abdominal closure after primary mesh positioning. We selected a mesh with a structure that allowed us to close the abdomen without creating adhesions and, at the same time, stimulating tissue repair. Two patients experienced local mesh infection, which has been kept under clinical control by antibiotics and daily medications till neoabdominal wall formation. The mesh was then removed. Another patient underwent mesh substitution for a suspicious fever. The last patient had mesh as a bridge for a subsequent myocutaneous flap from the thigh. All patients are in good health with well-functioning grafts and no need for parenteral nutrition. No enterocutaneous fistulae were detected.
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Affiliation(s)
- F Di Benedetto
- Liver and Multiorgan Transplant Unit, Sant'Orsola-Malpighi Hospital, University of Bologna, Massarenti no. 9, Bologna 40138, Italy
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26
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Faenza S, Bernardi E, Cuppini F, Gatta A, Lauro A, Mancini E, Petrini F, Pierucci E, Sangiorgi G, Santoro A, Varotti G, Pinna A. Intensive Care Complications in Liver and Multivisceral Transplantation. Transplant Proc 2005; 37:2618-21. [PMID: 16182765 DOI: 10.1016/j.transproceed.2005.06.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The complications concerning liver and intestinal transplant surgery have relevance for the field of intensive care because they share some characteristics with those following complex long-term surgery. Thus, in this article we shall try to describe complications that are specific to liver and multivisceral transplants. A review of the existing literature on this topic reveals a large number of studies dedicated to early as well as late surgical complications, and immunosuppressive treatment, while there are far fewer contributions describing complications exclusively concerning intensive care. We shall thus attempt to focus on certain aspects where, besides the literature data, we have personal experience. In particular we want to underline the implications of failure in the functional recovery of the graft; alterations in water, electrolyte, and glycemic balance; as well as neurological, respiratory, renal, nutritional, and infective complications.
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Affiliation(s)
- S Faenza
- Department of Surgery, Intensive Care and Transplantation, University of Bologna, Bologna, Italy
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27
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Testa G, Holterman M, John E, Kecskes S, Abcarian H, Benedetti E. Combined living donor liver/small bowel transplantation. Transplantation 2005; 79:1401-4. [PMID: 15912110 DOI: 10.1097/01.tp.0000157280.75015.14] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
We are reporting the first known case of sequential combined living donor liver/small bowel transplantation (LDL/SBT). A 2-year-old boy born with gastroschisis and intestinal malrotation lost his entire small bowel and colon shortly after birth. He underwent a living donor small bowel transplant at 1 year of age that was lost 4 months after implantation for posttransplant lymphoproliferative disease (PTLD). He recovered from PTLD but developed total parenteral nutrition (TPN)-induced liver failure. He received a combined left lateral liver and terminal ileum transplant that we chose to perform sequentially due to the presence of preformed antibodies against his mother's tissues. The mother had no complications and a cumulative hospital stay of 7 days. At 9 months postsurgery, the patient is on full enteral nutrition and has suffered neither technical complications nor rejection. The technique described here is reproducible and makes combined living donor LDL/SBT an alternative to combined cadaveric liver-small bowel transplant.
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Affiliation(s)
- Giuliano Testa
- Department of Surgery, Division of Transplantation, University of Illinois at Chicago, Chicago, Illinois 60612, USA.
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28
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29
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Ziring D, Tran R, Edelstein S, McDiarmid SV, Gajjar N, Cortina G, Vargas J, Renz JF, Cherry JD, Krogstad P, Miller M, Busuttil RW, Farmer DG. Infectious enteritis after intestinal transplantation: incidence, timing, and outcome. Transplantation 2005; 79:702-9. [PMID: 15785377 DOI: 10.1097/01.tp.0000154911.15693.80] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The study reviews the incidence, timing, and outcome of infectious enteritis (IE) after intestinal transplantation (ITx). METHODS A retrospective review of all patients who underwent ITx at a single institution between 1991 and 2003 was undertaken using database and medical records. Standard statistical analyses were performed. RESULTS Of 33 ITx recipients, 13 (39%) developed 20 culture- or biopsy-proven episodes of IE. Recipient demographics included the following: 10 males, median age 34 (10-585) months, 11 liver + intestine grafts, and two isolated intestine grafts. Infections were diagnosed a median of 76 days (32-1,800 days) after ITx. There were 14 viral (one cytomegalovirus, eight rotavirus, four adenovirus, one Epstein-Barr virus), three bacterial (Clostridium difficile), and three protozoal (one Giardia lamblia, two Cryptosporidium) infections. The bacterial infections tended to present earlier than the viral infections, and the most frequent presenting symptom was diarrhea. Complete resolution was achieved in 17 (94%) incidences with the appropriate antimicrobial or conservative therapy. It was interesting that there were seven rejection episodes documented by biopsy at the approximate time of diagnosis of IE. There were two graft losses: one because of adenoviral enteritis and one because of rejection after rotavirus enteritis. Three-year patient survival is 74% with no deaths directly attributable to IE. CONCLUSIONS IE can occur in 39% of recipients after ITx. Viral agents are the cause in two thirds of the cases. With supportive care and appropriate treatment, resolution is possible in the majority of cases. Differentiating rejection and infection on histopathology can be difficult and relies on cultures and immunostaining.
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Affiliation(s)
- David Ziring
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
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30
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Zou Y, Hernandez F, Burgos E, Martinez L, Gonzalez-Reyes S, Fernandez-Dumont V, Lopez G, Romero M, Lopez-Santamaria M, Tovar JA. Bacterial translocation in acute rejection after small bowel transplantation in rats. Pediatr Surg Int 2005; 21:208-11. [PMID: 15756565 DOI: 10.1007/s00383-004-1321-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2004] [Indexed: 12/15/2022]
Abstract
Acute rejection after small bowel transplantation (SBTx) may facilitate bacterial translocation (BT) and subsequent changes in the liver, spleen, and lungs. This study investigated whether BT occurs after acute rejection and whether this is followed by changes in the structure of the intestine and the phagocytic organs interposed between the gut and the general circulation. Orthotopic SBTx was performed in allogeneic (ALLO) rat-strain combinations (BN-Wistar, n=5). For comparison we used syngeneic SBTx (SYN) (BN-BN, n=6) controls. Animals were sacrificed on postoperative day 7. Mesenteric lymph nodes and portal and caval blood were cultured for aerobes and anaerobes. Escherichia coli beta-galactosidase DNA was assessed by polymerase chain reaction in the blood samples. Intestine, liver, spleen, and lung protein and DNA contents were measured. Histologic changes were graded according to standard criteria of acute rejection. For comparisons we used chi(2) and nonparametric Mann-Whitney test with a threshold of significance of p<0.05. ALLO rats lost more weight after SBTx than SYN rats (-13.02+/-4.39% vs. -8.04+/-5.08% of preoperative weight), although the difference was not significant (ns). A variable degree of graft rejection was histologically demonstrated in all ALLO rats, and DNA/protein content in the graft was significantly higher in this group (0.245+/-0.85 vs. 0.134+/-0.21, p<0.05). Gram-negative enteric bacteria were found in 4/5 ALLO and 4/6 SYN rats (ns), and aerobic Gram-positive bacteria in 2/5 and 3/6 (ns), respectively. Anaerobic growth occurred in mesenteric lymph nodes in one ALLO rat and in the bloodstream in another one. E. coli DNA was isolated in none of the ALLO but in two SYN rats (ns). BT was frequent after SBTx in both syngeneic and allogeneic strain combinations. Contrary to our expectations, BT after SBTx was not higher in ALLO group rats. However, anaerobic germs were isolated only in this group.
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MESH Headings
- Acute Disease
- Animals
- Bacterial Translocation
- Biomarkers/analysis
- Colony Count, Microbial
- Culture Media
- DNA, Bacterial/genetics
- Disease Models, Animal
- Escherichia coli/enzymology
- Escherichia coli/isolation & purification
- Escherichia coli/physiology
- Graft Rejection/metabolism
- Graft Rejection/microbiology
- Graft Rejection/pathology
- Intestine, Small/chemistry
- Intestine, Small/microbiology
- Intestine, Small/pathology
- Intestine, Small/transplantation
- Liver/chemistry
- Lung/chemistry
- Lymph Nodes/chemistry
- Lymph Nodes/pathology
- Mesentery
- Proteins/analysis
- Rats
- Rats, Inbred BN
- Rats, Wistar
- Spectrometry, Fluorescence
- Spleen/chemistry
- Tissue Culture Techniques
- beta-Galactosidase/genetics
- beta-Galactosidase/metabolism
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Affiliation(s)
- Y Zou
- Department of Pediatric Surgery, Hospital Universitario La Paz, Paseo de la Castellana 261, Madrid 28046, Spain
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31
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Saggi BH, Farmer DG, Yersiz H, Busuttil RW. Surgical advances in liver and bowel transplantation. ACTA ACUST UNITED AC 2005; 22:713-40. [PMID: 15541932 DOI: 10.1016/j.atc.2004.07.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Liver and intestinal transplantation are currently the treatments of choice for life-threatening hepatic and gastrointestinal failure. These technologies have evolved through contributions from the fields of immunology, anatomy, physiology, surgery, anesthesiology, critical care, ethics, epidemiology, and public health. Transplantation now accounts for the treatment of over 5,000 recipients per year who are in a state of organ failure. The available donor population, however, is not increasing to meet the demands of the faster growing recipient population. This discrepancy has led to the rapid development of novel strategies that require critical evaluation to build on the success rates in recent years. This article presents the most salient advances in liver and intestinal transplantation in the last 15 years.
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Affiliation(s)
- Bob H Saggi
- Division of Immunology and Organ Transplantation, Department of Surgery, University of Texas Health Sciences Center at Houston, TX 77030, USA.
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32
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33
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Moreno Villares JM, Galiano Segovia MJ, Urruzuno Tellería P, Gomis Muñoz P, León Sanz M. [Therapeutic alternatives in intestinal failure]. An Pediatr (Barc) 2004; 60:550-4. [PMID: 15207167 DOI: 10.1016/s1695-4033(04)78325-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Long-term parenteral nutrition is effective in the treatment of intestinal failure. Equally, the results of intestinal transplantation (IT) are promising. The choice of one or other form of treatment depends on the balance between the advantages and disadvantages of each. Based on these premises, we analyzed the outcome of home parenteral nutrition (HPN) for intestinal failure in our patients. METHODS Intestinal failure was considered when parenteral nutrition was required for more than 5 months. In the 14 patients included in the HPN program since 1993, we reviewed the indication of HPN as well as their suitability for IT. RESULTS Five of the 14 patients received HPN for causes other than intestinal failure. Of the remaining nine patients, four had severe motility disorder, three had short bowel syndrome, and two had protracted diarrhea of infancy. All these patients would be potential candidates for IT. Five patients were weaned off HPN because of intestinal adaptation between 2.5 and 13 months after starting HPN. One patient died because of lack of venous access. Three patients currently continue on HPN. CONCLUSION Intestinal rehabilitation constitutes the best option for patients with intestinal failure. HPN offers the best interim treatment while waiting for adaptation. IT should be reserved for those patients with severe complications due to HPN. Nevertheless, it may become a real option for those with indefinite HPN. HPN and IT should be considered as complementary treatments.
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Affiliation(s)
- J M Moreno Villares
- Unidad de Nutrición Clínica, Hospital Universitario 12 de Octubre, Ctra. de Andalucía, km. 5,400, 28041 Madrid, Spain.
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34
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Magee JC, Bucuvalas JC, Farmer DG, Harmon WE, Hulbert-Shearon TE, Mendeloff EN. Pediatric transplantation. Am J Transplant 2004; 4 Suppl 9:54-71. [PMID: 15113355 DOI: 10.1111/j.1600-6143.2004.00398.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Analysis of the OPTN/SRTR database demonstrates that, in 2002, pediatric recipients accounted for 7% of all recipients, while pediatric individuals accounted for 14% of deceased organ donors. For children fortunate enough to receive a transplant, there has been continued improvement in outcomes following all forms of transplantation. Current 1-year graft survival is generally excellent, with survival rates following transplantation in many cases equaling or exceeding those of all other recipients. In renal transplantation, despite excellent early graft survival, there is evidence that long-term graft survival for adolescent recipients is well below that of other recipients. A causative role for noncompliance is possible. While the significant improvements in graft and patient survival are laudable, waiting list mortality remains excessive. Pediatric candidates awaiting liver, intestine, and thoracic transplantation face mortality rates generally greater than those of their adult counterparts. This finding is particularly pronounced in patients aged 5 years and younger. While mortality awaiting transplantation is an important consideration in refining organ allocation strategies, it is important to realize that other issues, in addition to mortality, are critical for children. Consideration of the impact of end-stage organ disease on growth and development is often equally important, both while awaiting and after transplantation.
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Affiliation(s)
- John C Magee
- Scientific Registry of Transplant Recipients/University of Michigan, Ann Arbor, MI, USA.
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35
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Renz JF, McDiarmid SV, Edelstein S, Yersiz H, Hisatake GM, Gordon S, Saggi BH, Busuttil RW, Farmer DG. Application of combined liver-intestinal transplantation as a staged procedure. Transplant Proc 2004; 36:314-5. [PMID: 15050143 DOI: 10.1016/j.transproceed.2003.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Liver-intestinal transplantation is a complex surgical procedure that historically has required prolonged operative periods. This report is the first series where liver-intestinal transplantation was performed as a staged procedure. Specifically, allograft reperfusion was followed by resuscitation and stabilization in an intensive care unit before completion of the transplant procedure. Triage of recipients to the intensive care unit following allograft reperfusion was determined at the time of operation and was based upon the clinical condition of the recipient including hemodynamic stability, evidence of coagulopathy, and assessment of early liver function. Medical stabilization was followed by completion of the transplant procedure and definitive abdominal closure within 72 hours. The application of combined liver-intestinal transplantation as a staged procedure demonstrated no effect upon early graft function, incidence of complications, or ability to perform a definitive abdominal closure.
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Affiliation(s)
- J F Renz
- Center for Liver Disease and Transplantation, College of Physicians and Surgeons of Columbia University, New York-Presbyterian Hospital, New York, NY 10032, USA.
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36
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Farmer DG, McDiarmid SV, Edelstein S, Renz JF, Hisatake G, Cortina G, Fondevila C, Correa M, Rhodes S, Zafar A, Chavez Y, Yersiz H, Busuttil RW. Induction therapy with interleukin-2 receptor antagonist after intestinal transplantation is associated with reduced acute cellular rejection and improved renal function. Transplant Proc 2004; 36:331-2. [PMID: 15050149 DOI: 10.1016/j.transproceed.2004.01.099] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To determine the effectiveness of induction immunotherapy with interleukin-2 receptor antagonists (IL2RA) after intestinal transplantation (IT). METHODS A single-center, retrospective study was undertaken of all patients undergoing IT using existing medical records and database. Immunotherapy was either triple (standard maintenance triple therapy [SMTT]) or IL2RA [induction IL2RA plus SMTTx] or OKT3 [induction antilymphocyte preparations plus SMTTx]). Data was collected for the first 175 postoperative days. Outcomes included pretransplant renal function, posttransplant serum creatinine normalized to age (nl-sCR), rejection (ACR), and survival. Standard statistical analysis was undertaken. RESULTS There were no significant differences in the groups: triple (n = 10, median age 3.5 years, cGFR 106 +/- 44 mL/min), IL2RA (n = 13, median age 3.2 years, cGFR 101 +/- 61 mL/min), OKT3 (n = 4, median age 7.7 years, cGFR 104 +/- 27 mL/min). nl-sCR was significantly (P <.01) lower in IL2RA at most postoperative weeks. IL2RA had significantly fewer rejection and infectious episodes than the other two groups. Three-year patient survival was 92% in IL2RA versus 50% triple and OKT3. CONCLUSIONS IL2RA immunotherapy after IT is associated with a lower incidence of renal dysfunction as compared with historical controls. Furthermore, IL2RA therapy resulted in a lower incidence of rejection and improved survival. IL2RA should be considered in select patients undergoing IT.
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Affiliation(s)
- D G Farmer
- Dumont-UCLA Transplant Program, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
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37
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Farmer DG, McDiarmid SV, Edelstein S, Yersiz H, Vargas J, Cortina G, Renz JF, Fondevila C, Hisatake G, Reyen L, Correa M, Rhodes S, Zafar A, Chavez Y, Busuttil RW. Improved outcome after intestinal transplantation at a single institution over 12 years. Transplant Proc 2004; 36:303-4. [PMID: 15050139 DOI: 10.1016/j.transproceed.2004.01.098] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the outcomes of patients undergoing intestinal transplantation (IT). METHODS Retrospective review was undertaken using existing medical records and database. RESULTS Between November 1991 and May 2003, 114 patients were referred for consideration for IT, of which 33 patients received 37 intestinal allografts. All patients had intestinal failure and all patients had significant complications from total parenteral nutrition (TPN). TPN was the predominant cause of liver failure (63%). Combined liver intestinal grafts were used in the majority of patients. Overall 1- and 3-year patient survival is 77% and 52% with patients transplanted since 1999 having a 1- and 3-year survival of 94% and 73%, respectively. The most common cause of death was sepsis. No graft or patient was lost to cytomegalovirus or Epstein-Barr virus disease. Twenty-seven percent of allografts were lost to rejection. Long-term TPN independence is 82% for grafts more than 30 days after IT. Statistical analysis revealed several important factors impacting outcome. CONCLUSIONS Successful IT defined as prolonged patient and graft survival and TPN independence can be readily achieved in select patients with IF and complications related to TPN therapy. Outcomes have improved with experience gained and control of viral infections and rejection.
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Affiliation(s)
- D G Farmer
- Dumont-UCLA Transplant Program, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
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38
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Sudan D, Horslen S, Botha J, Grant W, Torres C, Shaw B, Langnas A. Quality of life after pediatric intestinal transplantation: the perception of pediatric recipients and their parents. Am J Transplant 2004; 4:407-13. [PMID: 14961994 DOI: 10.1111/j.1600-6143.2004.00330.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The objective was to examine the perception of physical and psychosocial functioning of pediatric intestinal transplant recipients who are beyond the perioperative period and compare these with normal and chronically ill children. Child and parent forms of the Child Health Questionnaire were administered to all 29 pediatric intestinal transplant recipients between the ages of 5 and 18 years who had had a small bowel transplantation 1 year previous and had a functional allograft. Comparison was made with published norms and scores for pediatric patients on hemodialysis. Intestinal transplant recipients (on average 5 years after intestinal transplantation and at a mean age 11 years) reported similar scores in all domains compared with normal children. Parents of intestinal transplant recipients noted decreased function in several domains related to their child's general health, physical functioning, and the impact of the illness on parental time, emotions and family activities. Intestinal transplant recipients beyond the perioperative period perceive their physical and psychosocial functioning as similar to normal school children. Parental proxy assessments differ from the recipients, with the parent's perception of decreased general health and physical functioning for intestinal transplant recipients compared with norms.
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Affiliation(s)
- Debra Sudan
- Organ Transplantation Program, Nebraska Medical Center, University of Nebraska, Omaha, NB, USA.
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39
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Roberts JP, Brown RS, Edwards EB, Farmer DG, Freeman RB, Wiesner RH, Merion RM. Liver and intestine transplantation. Am J Transplant 2004; 3 Suppl 4:78-90. [PMID: 12694052 DOI: 10.1034/j.1600-6143.3.s4.8.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- John P Roberts
- University of California San Francisco, San Francisco, CA, USA
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40
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Tannuri U, Gomes VA, Troster EJ. Concomitant involvement of the small intestine and the distal esophagus in an infant with massive necrotizing enterocolitis. ACTA ACUST UNITED AC 2004; 59:131-4. [PMID: 15286833 DOI: 10.1590/s0041-87812004000300007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Necrotizing enterocolitis is a disease of the newborn that may involve the small intestine and/or the colon, and the stomach. To our knowledge, massive necrosis of the small intestine with concomitant involvement of the esophagus has never been reported. A case of a 6-month-old boy with necrotizing enterocolitis and pan-necrosis of the small intestine, cecum, and the lower third of the esophagus is presented. After 70 days of treatment, intestinal transit was established by an anastomosis between the first centimeter of jejunum and the ascending colon. Finally, esophageal transit was established by a total gastric transposition with cervical esophagogastric anastomosis. The patient was maintained under total parenteral nutrition, and after 19 months he developed fulminant hepatic failure due to parenteral nutrition; he then underwent combined liver and small bowel transplantation. After 2 months, the patient died due to undefined neurologic complications, probably related to infection or immunosuppressive therapy.
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Affiliation(s)
- Uenis Tannuri
- Pediatric Intensive Care Unit, Albert Einstein Jewich Hospital, Pediatric Surgery Division, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil.
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Benedetti E, Panaro F, Holterman M, Abcarian H. Surgical approaches and intestinal transplantation. Best Pract Res Clin Gastroenterol 2003; 17:1017-40. [PMID: 14642863 DOI: 10.1016/s1521-6918(03)00081-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The surgical treatment of short-bowel syndrome has been traditionally based on the correction of mechanical obstruction, which is responsible for bacterial overgrowth syndrome, or on intestinal expansion procedures. Since the introduction of clinical intestinal transplantation by Lillehei in 1964, there have been remarkable advances in the immunosuppressive regimens to control rejection and in preservation techniques, monitoring and critical care. Newer and more powerful immunosuppressants have helped to transform intestinal transplantation into a clinical reality-transplantation can now be a life-saving procedure for patients with intestinal failure. It is currently indicated in the event of life-threatening complications of an underlying disease or from total parenteral nutrition (TPN). Rehabilitation in successful cases is excellent.
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Affiliation(s)
- Enrico Benedetti
- University of Illinois at chicago, 1Division of Transplantation, 840 S. Wood St., Chicago, IL 60612, USA.
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Loinaz C, Kato T, Nishida S, Weppler D, Levi D, Dowdy L, Madariaga J, Nery JR, Vianna R, Mittal N, Tzakis A. Bacterial infections after intestine and multivisceral transplantation. Transplant Proc 2003; 35:1929-30. [PMID: 12962852 DOI: 10.1016/s0041-1345(03)00728-0] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The frequency of bacterial infections (BI) in intestinal transplant (IT) patients is high with sepsis being the leading cause of death after this procedure. We herein report our experience with major BI to ascertain the incidence, microbiological and clinical factors, risk factors and outcome. MATERIALS AND METHODS 124 patients (72 children and 52 adults) received 135 grafts: namely, 39 isolated intestine, 33 liver-intestine and 63 multivisceral. Only major BI were considered, namely, those associated with serious morbidity/mortality requiring specific therapy. Patient data were retrieved from computerized databases, flow-charts, and medical records. RESULTS 92.7% patients showed BI. There were 327 episodes, representing 2.6 episodes/patient (2.8/patients with infection): 193 episodes of bacteremia (1.7/patient with BI) including 29.5% due to catheter related sepsis, 16.5% from abdominal source, 5.7% from respiratory origin and 4.1% from the wound. The organ locations includes 46 respiratory infections, 33 intraabdominal abscesses or infected fluid collections, 8 diffuse peritonitis, 34 wound infections and other miscellaneous sites: empyema, soft tissue infections, cholangitis em leader etc. Median time of infection was nine days after surgery (mean 22+/-3 days), with 67.7% patients having at least one BI before the end of the first month. Infection was present in 76.2% of the 63 deceased patients. An infectious episode during month 1, a clinically manifest abdominal infection and a positive intraabdominal culture had negative impacts on patient survival. CONCLUSIONS BI are common and early complications after IT. The high rate of bacteremia, line sepsis and abdominal and respiratory infections reflect the recipient's condition, with chronic deterioration superimposed with the effects of prolonged abdominal visceral surgery.
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Affiliation(s)
- C Loinaz
- Division of Transplantation, University of Miami School of Medicine, Miami, Florida, USA
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Yersiz H, Renz JF, Hisatake GM, Gordon S, Saggi BH, Feduska NJ, Busuttil RW, Farmer DG. Multivisceral and isolated intestinal procurement techniques. Liver Transpl 2003; 9:881-6. [PMID: 12884206 DOI: 10.1053/jlts.2003.50155] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Improved outcomes in multivisceral and isolated intestinal transplantation have generated increased demand for these procedures. Enhanced recognition of potential multivisceral/intestinal donors and widespread application of advanced organ procurement techniques is necessary in the current climate of organ scarcity. This manuscript details the multivisceral and isolated intestinal procurement techniques currently performed at the University of California Los Angeles.
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Affiliation(s)
- Hasan Yersiz
- Dumont-UCLA Transplant Center, Department of Surgery, University of California at Los Angeles, Los Angeles, CA 90095-7054, USA.
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