Intestinal transplantation for children with short bowel syndrome

Outcomes of Children With Short Bowel Syndrome: Experiences in a Multidisciplinary Intestinal Rehabilitation Unit Over Two Decades

BACKGROUND

Short bowel syndrome (SBS) is a rare but serious form of organ failure, and patients with SBS depend on total parenteral nutrition (PN) to maintain growth and development. The present study aimed to evaluate the experiences and outcomes of children with SBS managed by a multidisciplinary intestinal rehabilitation programme in a tertiary paediatric centre.

METHODS

A retrospective single-centre analysis of all paediatric patients with a clinical diagnosis of SBS between 2001 and 2022 was performed. Clinical outcomes and their predictors were extracted and analysed.

RESULTS

Of the 64 children included in the study, 43 (67%) had extensive necrotising enterocolitis. The median bowel length was 45 cm (interquartile range (IQR) = 18-65) and 18.9% (IQR = 10-28.5) of the expected length based on age. Over a mean follow-up period of 8.9 years, 57 patients (89%) survived, and 50 (78%) weaned off PN. The presence of intestinal failure-associated liver disease (IFALD) (OR = 6.375, p = 0.02) and patients managed before the introduction of fish oil-based PN in 2007 (OR = 5.895, p = 0.001) were significant predictors of mortality. There was an overall improvement in survival over time (p = 0.003). Ultrashort bowel length was not associated with significantly higher mortality (OR = 1.1, p = 0.65) but was a poor prognostic factor for weaning off PN (OR = 3.57, p = 0.004). Among all patients who weaned off PN, two had bowel lengthening procedures and one received a glucagon-like peptide 2 (GLP-2) analogue.

CONCLUSIONS

A multidisciplinary intestinal rehabilitation programme offers a comprehensive approach for patients with SBS and has been shown to be effective with favourable outcomes. Improvements in the choice of PN and the development of new treatment strategies potentially improved the survival and enteral autonomy of SBS patients.

LEVEL OF EVIDENCE

III.

Invariant natural killer T cells infiltrate intestinal allografts undergoing acute cellular rejection

Immunological responses in human intestinal allografts are poorly understood and accurate diagnosis of acute cellular rejection remains difficult. Here, human intestinal allografts were analyzed by multi-color quantitative fluorescent immunohistochemical morphometry in order to monitor the clinical course of rejection. Morphometry gave two-dimensional plots based on size and circularity, and identified phenotypes of individual cells infiltrating the allograft by fluorescent staining. Using this method, invariant TCRVα24(+) NKT (iNKT) cells were observed in the intestinal allograft during rejection. Because these were not identified in the normal donor intestine before surgery, this finding was considered to be a signature of acute cellular rejection of the intestinal allograft. Infiltrating iNKT cells released IL-4 and IL-5, Th2-related cytokines that antagonize the Th1 responses that induce acute cellular rejection. Histological observation suggested eosinophilic enteritis in the mucosa with elevation of IL-4 and IL-5. In conclusion, iNKT cells were recruited to the intestine; however, because higher levels of IL-4 and IL-5 may contribute to eosinophilic enteritis, timely steroid administration is recommended for allograft injury due to enteritis, as well as acute cellular rejection.

Microvillous inclusion disease: how to improve the prognosis of a severe congenital enterocyte disorder

BACKGROUND AND OBJECTIVE

Microvillous inclusion disease (MVID) is a rare congenital enterocyte disorder causing severe diarrhea and intestinal failure. The objective of this study was to analyze clinical evolution and the most frequent complications of MVID in children receiving parenteral nutrition (PN) and after small-bowel transplantation (SBTx) with the aim to improve treatment strategies and prognosis.

PATIENTS AND METHODS

From 1995 to 2009, 24 patients (16 boys, median follow-up 4.7 years, range: from birth to 23.5 years) with MVID were admitted to our unit. The recorded parameters included growth, neurological development, liver and renal functions, bone disease, and outcome.

RESULTS

Almost half of the children were from consanguineous families from the Mediterranean area. All of the patients completely depended on PN. Four children died of PN complications before 4 years of age. Before or without SBTx, growth failure was common (mean height -2.5 standard deviations [SD]), as was developmental delay (12/24), liver (20/22 with fibrosis) or kidney disease (3/23 with moderate renal insufficiency), and osteoporosis (6/24). Thirteen children underwent SBTx (9 isolated, 4 combined with liver Tx) at a median age of 3.5 years. Follow-up after SBTx was 0.4 to 14 years. Patient survival rates were 63% without SBTx and 77% with SBTx. After SBTx, 4 children experienced catch-up growth.

CONCLUSIONS

PN in MVID is difficult to manage and requires expertise. Despite improved results in expert centers, the risk of death or irreversible sequelae is higher with PN than after Tx. SBTx, despite being complicated, remains the only hope to improve the quality of life and long-term prognosis of these children.

Application of a self-made swivel intravenous transfusion device in constructing allogenic small bowel transplantation rejection model in rats

BACKGROUND

Lacking a long-term continuous intravenous infusion device for experimental animals is the biggest obstacle to constructing an allogenic small bowel transplantation rejection model.

OBJECTIVE

To establish a rat heterotopic small bowel transplantation model with the use of a swivel device for intravenous transfusion.

METHODS

The randomized block design of controlled observations included 90 inbred male F344/NCrl BR rats as donors and 90 LEW/Crl rats as recipients. On the basis of body weight, the rats were divided into three groups each with 30 pairs of rats. Group 1, the control group, underwent small bowel transplantation. Group 2, the transfusion group, received small bowel transplantation and continuous infusion of parenteral nutrient solution. Group 3, the tacrolimus (FK506) treatment group, received small bowel transplantation, continuous infusion of parenteral nutrient solution, and intravenous injection of FK506. The general status and survival time of transplanted rats were observed for 5 weeks.

RESULTS

The operative success rate was 100%. The survival rate was 83.3% (25/30) in the control group; and 96.7% (58/60) in groups 2 and 3 (P = .039). The mean survival time of the FK506 group was 22.1 +/- 13.4 days, which was significantly higher than that in the transfusion group (10.4 +/- 2.9 days, P = .023).

CONCLUSION

The simple, practical swivel intravenous infusion device provided treatment for more than 30 days, a useful tool for heterotopic segmental small bowel transplantation.

Bilirubin impairs intestinal regrowth following massive small bowel resection in a rat model

OBJECTIVES

The purpose of the present study was to evaluate the effects of exogenous bilirubin on structural intestinal adaptation, cell proliferation, and apoptosis in a rat model of short bowel syndrome (SBS).

MATERIALS AND METHODS

Male Sprague-Dawley rats were divided into 5 experimental groups: Sham rats underwent bowel transection and reanastomosis, sham multiple doses of bilirubin (MDB) rats underwent bowel transection and were treated with bilirubin, SBS rats underwent a 75% small bowel resection, SBS-SDB (single dose bilirubin) rats underwent a bowel resection and were treated with a single dose of bilirubin, and SBS-MDB underwent a bowel resection and were treated with 3 doses of bilirubin. Bilirubin was administered intraperitoneally from the 7th day through the 14th day postoperatively. Serum total bilirubin concentration over time was evaluated in 5 SBS-SDB rats following a single intraperitoneal dose. Total bilirubin, alanine aminotransferase, and aspartate aminotransferase in serum and parameters of intestinal adaptation, enterocyte proliferation, and enterocyte apoptosis were determined on day 15.

RESULTS

SBS-SDB and SBS-MDB animals demonstrated lower ileal bowel and mucosal weights, jejunal mucosal DNA and ileal mucosal protein, and jejunal and ileal villus height and crypt depth (vs SBS animals). Bilirubin-treated rats showed a lower apoptotic index in jejunum and ileum and a trend toward an increase in cell proliferation in jejunum and ileum (vs SBS group).

CONCLUSIONS

In a rat model of SBS, exogenous bilirubin inhibits structural intestinal adaptation. Increased cell proliferation and decreased apoptosis may be considered adaptive mechanisms that maintain cell mass.

Formation of microchimerism in rat small bowel transplantation by splenocyte infusion

AIM: To investigate the effect of donor splenocyte infusion combined with cyclosporine A (CsA) on rejection of rat small bowel transplantation (SBT).

METHODS: Male Sprague-Dawley (SD) rats and female Wistar rats weighing 230-270 g were used as donors and recipients respectively in the study. Heterotopic small bowel transplantation was performed. The rats were divided into three groups: group one receiving allotransplantation (SD→Wistar), group two receiving allotransplantation (SD→Wistar) + donor splenocyte infusion, group three receiving allotransplantation (SD→Wistar) + donor splenocyte infusion + CsA followed by CsA 10 mg/kg per day after transplantation, in which recipient Wistar rats were injected with 2 ×10⁸ SD splenocytes 28 d before transplantation, and treated with CsA after transplantation. Finally, the specific DNA fragment of donor Y chromosome was detected in recipient peripheral blood and skin by PCR. The survival time after small bowel transplantation was observed. Gross and histopathological examinations were performed.

RESULTS: The survival time after small bowel trans-plantation was 7.1 ± 1.2 d in group 1, 18.4 ± 3.6 d in group 2 and 31.5 ± 3.1 d in group 3. The survival time was significant longer (P < 0.01) in group 3 than in groups 1 and 2. The gross and histopathological examination showed that the rejection degree in group 3 was lower than that in groups 1 and 2.

CONCLUSION: Donor splenocyte infusion combined with CsA decreases remarkably the rejection and prolongs the survival time after rat small bowel transplantation.

Histopathologic characteristics of human intestine allograft acute rejection in patients pretreated with thymoglobulin or alemtuzumab

BACKGROUND

We report herein the histopathologic characteristics of human intestine allograft acute rejection in a consecutive series of 48 patients receiving small bowel transplantations and treated with a preconditioning protocol between July 4, 2001 and January 31, 2004.

METHODS

Recipient pretreatment was with an i.v. infusion of 5-10 mg/kg thymoglobulin or 30-60 mg of alemtuzumab (Campath 1H) over several hours prior to revascularization. Postoperative treatment was limited to tacrolimus (target 12-h trough level 10-15 ng/mL) unless additional drugs were needed to treat breakthrough rejection.

RESULTS

A total of 3,497 biopsies of the allograft jejunum and/or ileum were obtained. A recently validated histological grading schema was prospectively utilized to grade acute rejection. A total of 116 acute rejection episodes were diagnosed (48 indeterminate, 36 mild, 11 moderate, and 21 severe). Several unique histopathologic features of allograft acute rejection were observed in the pretreated patients. First, scattered lamina propria neutrophilic inflammation often precedes the onset of acute rejection. Second, acute rejection is often associated with more prominent eosinophils in lamina propria or eosinophilic cryptitis. Third, certain acute rejection episodes are characterized by absence of crypts with intact surface villous epithelium. Finally, the mucosal damage associated with moderate or severe acute rejection can completely recover after additional immunosuppressive treatment.

CONCLUSION

This study describes several characteristic histopathologic features of allograft small bowel acute rejection associated with thymoglobulin or alemtuzumab preconditioning. Recognition of these unique histopathologic features will enable accurate diagnosis and ensure successful weaning of immunosuppressive drugs.

Operative strategies for necrotizing enterocolitis: The prevention and treatment of short-bowel syndrome

Necrotizing enterocolitis (NEC) is the leading cause of short-bowel syndrome (SBS) in infancy. Studies on the acute medical and surgical management of NEC have traditionally focused on short-term morbidity and mortality, with less emphasis on long-term outcomes. Acute surgical management of NEC involves the often competing priorities of controlling sepsis and preserving bowel length. Bowel-preserving strategies for NEC, designed to limit SBS, are based on peritoneal drainage, limited resection, or a combination of both. Drainage-based strategies are generally favored in smaller neonates, while laparotomy-based strategies are favored in larger patients, especially those with a more limited extent of intestinal injury. Comparisons of drainage-based approaches and resection-based approaches are limited by confounding variables, and neither approach is clearly superior with regard to subsequent SBS. These traditional as well as more creative approaches to bowel preservation have application in NEC, yet they depend on a series of patient and treatment characteristics that include the ability of diseased but viable bowel to recover both absorptive and motility function after acute NEC, the ability of the infant to tolerate appropriately drained intraperitoneal contamination, and the ability of the injured intestine to subsequently undergo intestinal adaptive change. In addition, there are a series of operative options that have been designed to mitigate the impact of SBS once it is established. These procedures are not uniquely applied exclusively for NEC-induced SBS. However, strategies that slow intestinal transit, improve peristaltic function, or enhance mucosal absorptive function each have application in the management of SBS.

Gene expression profile in rat small intestinal allografts after cold preservation/reperfusion

AIM: To determine the changes of gene expression profile in small intestinal allografts in rats after cold preservation/reperfusion, and to identify the genes relevant to cold preservation/reperfusion injury.

METHODS: Heterotopic segmental small bowel transpla-ntation was performed in six rats with a sham operation and they were used as controls. Total RNA was extracted from the allografts (experimental group) and normal intestines (control group) 1 h after cold preservation/reperfusion, and then purified to mRNA, which was then reversely transcribed to cDNA, and labeled with fluorescent Cy5-dUTP and Cy3-dUTP to prepare hybridization probes. The mixed probes were hybridized to the cDNA microarray. After high-stringent washing, the fluorescent signals on cDNA microarray chip were scanned and analyzed.

RESULTS: Among the 4 096 target genes, 82 differentially expressed genes were identified between the two groups. There were 18 novel genes, 33 expression sequence tags, and 31 previously reported genes. The selected genes may be divided into four classes: genes modulating cellular adhesion, genes regulating cellular energy, glucose and protein metabolism, early response genes and other genes.

CONCLUSION: A total of 82 genes that may be relevant to cold preservation/reperfusion injury in small intestinal allografts are identified. Abnormal adhesion between polymorphonuclears and endothelia and failure in energy, glucose and protein metabolism of the grafts may contribute to preservation/reperfusion injury. The functions of the novel genes identified in our study need to be clarified further.

Impaired absorption of marked oligopeptide Glycine-I Tyrosine-Glycine after successful autologous-allotopic ileal mucosa transplantation in beagles

PURPOSE

After establishing a method for ileal mucosa transplantation in an animal model, the authors investigated the absorptive capacity for oligopeptides of the transplanted mucosa.

METHODS

In 14 beagle dogs the authors transplanted ileal mucosa in a vascularized demucosed segment of the transverse colon. The colonic wall-ileal mucosa complex then was integrated in the ileal continuity. Six animals were lost owing to operative complications. Absorptive capacity for oligopeptides was measured in the remaining 8 animals with the iodine 131 (131I)-marked tripeptide glycine-tyrosine-glycine before and 4 weeks after transplantation. The results were compared and analyzed with the Student's t test for matched pairs. Blood concentrations of the marked tripeptide with P value less than .05 were considered as a significant reduction in the absorptive capacity of the transplanted ileal mucosa. After fixation with glutaraldehyd graft, uptake of the colonic wall-ileal mucosa complex was evaluated histologically in 8 animals.

RESULTS

In all 8 animals, a 100% graft uptake was verified in all sections. Fifteen minutes after application of 15 MBc Glycine-131I-Tyrosine-Glycine there was no significant difference in the absorption between normal and transplanted ileal mucosa. After 30 minutes, the absorption of the transplanted ileal mucosa showed a tendency (P < .1) for an impaired uptake of the marked tripeptide. However, 60 minutes after application the difference in the absorptive capacity of the transplanted ileal mucosa was significant (P < .05).

CONCLUSIONS

Autologous allotopic ileal mucosa transplantation is feasible; however, an impaired absorption of oligopeptides of the transplanted mucosa 4 weeks after transplantation could be observed.

Absorption of D(+)-xylose, cobalamin, and folic acid after autologic-allotopic ileum mucosa transplantation in beagles

BACKGROUND/PURPOSE

Ileum mucosa transplantation in a demucosed colon coat was developed as a new method for small bowel elongation. In an animal model, the authors investigated the absorptive capacity of the transplanted mucosa for D(+)-xylose, cobalamin (vitamin B12), and folic acid.

METHODS

Ileum mucosa was transplanted in a vascularized demucosed segment of transverse colon in 18 beagle dogs. The colon coat-ileum mucosa complex then was integrated in the ileal continuity. Absorptive capacity for D(+)-xylose, cobalamin, and folic acid was measured before and 4 weeks after transplantation. The results were compared and analyzed with the Students' t test for matched pairs. All determined blood values with P values less than.05 were considered to show a significant reduction in the absorptive capacity of the transplanted ileum mucosa.

RESULTS

Fifteen minutes after application there was no significant difference in the absorption of D(+)-Xylose and cobalamin between normal and transplanted ileum mucosa (P >.1). Absorption of folic acid in the transplanted segment was lower but not significant (P <.1). After 30 minutes D(+)-xylose and cobalamin again showed no difference between the absorptive capacity of normal and transplanted ileum mucosa (P >.1), whereas folic acid continued with the tendency toward an impaired absorption (P <.1). However, after 60 minutes, the difference of the absorptive capacity of the transplanted ileum mucosa was significant (P <.05) for folic acid. D(+)-xylose showed a tendency for an impaired uptake (P <.1), whereas absorption of cobalamin did not differ significantly after transplantation (P >.1).

CONCLUSIONS

Experimental autologic-allotopic ileum mucosa transplantation is a feasible new method for small bowel elongation in an animal model. Examination of the absorptive capacity of the transplanted ileum mucosa showed a normal uptake for cobalamin, while there was an impaired absorption of D(+)-xylose and folic acid.

[Therapeutic alternatives in intestinal failure]

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.

New perspectives for children with microvillous inclusion disease: early small bowel transplantation

BACKGROUND

Microvillous inclusion disease (MVID) is a congenital intestinal epithelial cell disorder leading to lifelong intestinal failure. Despite long-term total parenteral nutrition, life expectancy is extremely reduced because of metabolic or septic complications or liver failure.

METHODS

Twelve patients with early-onset MVID were evaluated between 1995 and 2002 for the possibility of small bowel transplantation (SbTx). Three patients died before they could be placed on the waiting list for SbTx, and one patient is still awaiting SbTx. SbTx was contraindicated in one patient.

RESULTS

Seven of 12 patients (six boys and one girl) underwent transplantation (three SbTxs and four combined liver-SbTxs). Actuarial survival rates were 100% and 75% in the SbTx and combined liver-SbTx groups, respectively, with a mean follow-up of 3 years (1.1-8.5 years). In contrast, the survival rate was only 40% in the subgroup of five patients who did not undergo transplantation. After transplantation, all patients were weaned from parenteral nutrition: the five patients with an additional colon graft were weaned within 36 days as opposed to the others without colonic transplant who obtained full intestinal autonomy several months after transplantation. The only two surviving patients who did not undergo SbTx remain highly dependent on total parenteral nutrition, which is complicated by repeated episodes of metabolic decompensation.

CONCLUSIONS

SbTx alone or in combination with the liver is highly successful in children with MVID, offering them a long-term perspective for the first time. Associated colon grafting markedly improves the outcome and quality of life after SbTx in patients with MVID.

Histologic changes in neuronal innervation of the ileum mucosa after autologic-allotopic ileum mucosa transplantation

INTRODUCTION

After successful experimental autologic-allotopic ileum mucosa transplantation, we investigated the remodeling of the transplanted submucous and mucous plexus, which is essential for the motility of the created colon coat-ileum mucosa complex.

METHOD

In 8 beagles we transplanted ileum mucosa in a demucosed vascularized transverse colon segment, which was reanastomosed with the small bowel immediately after transplantation. Four weeks later the animals were sacrificed and histology specimens taken from the anastomosis site of the colon coat-ileum mucosa complex, allowed comparison between transplanted and normal mucosa in the same section. After fixation in 4% formaldehyde and PBS the samples were embedded in paraffin and 7 micro m sections were prepared. The distribution of nerve fibers and submucous ganglia were examined in dewaxed sections, using antisera against protein gene product (PGP9.5), a general neuronal marker.

RESULTS

The submucosal ganglia were prominent in all samples but they were smaller and the submucous nerve cells within the ganglia were less numerous compared to the controls. The innervation of the transplanted ileum mucosa was reduced as the number of nerve fibers in the mucosal villi was decreased. Besides these neuromorphologic changes the transplanted mucosa showed a slightly higher rate of shortened villi compared to normal ileum mucosa.

CONCLUSIONS

After ileum mucosa transplantation the submucosal ganglia are smaller and less numerous. Furthermore there is a considerable loss of nerve fibers in the mucosal layer. Additionally a loss of microvilli in the transplanted ileum mucosa was found. Whether these findings represent a state of remodeling or a slow atrophy of the enteric nervous system in the transplanted areas is currently under investigation.

Influence of liver nonparenchymal cell infusion combined with cyclosporin A on rejection of rat small bowel transplantation

AIM: To investigate the effect of liver nonparenchymal cell infusion combined with cyclosporin A (CsA) on rejection of heterostrain rat small bowel transplantation.

METHODS: The liver nonparenchymal cell suspension was prepared by density gradient centrifugation method with Percoll centrifugal solution. Heterotopic small bowel transplantation was performed. Then the rats were divided into four groups. Group one: homogenic transplantation (F344/N→F344/N), group two: allotransplantation (F344/N →Wistar), group three: allotransplantation (F344/N→Wistar) + CsA, with CsA 10 mg·kg^-1·d^-1 after transplantation, group four: allotransplantation + CsA (F344/N→Wistar) + liver nonparenchymal cell infusion + CsA (F344/N→Wistar), in which recipient Wistar rats had been injected with 2 × 10⁸ F344/N liver nonparenchymal cells 20 days before transplantation, and treated with CsA after transplantation. Finally, the survival time after small bowel transplantation, gross and histopathological examination, and IL-2 levels in serum were observed.

RESULTS: The survival time after small bowel transplantation was 7.14 ± 0.33 d, 16.32 ± 0.41 d and 31.41 ± 0.74 d in group 2, 3, and 4, respectively. The survival time was significant longer (P < 0.01) in group 4. The gross and histopathological examination showed that the rejection degree in group 4 was lower than those in groups 2 and 3. Serum IL-2 level in group 4 was also lower than those in groups 2 and 3 (P < 0.01).

CONCLUSION: Liver nonparenchymal cell infusion combined with CsA can prolong the survival time of rat small bowel transplantation, and the anti-rejection effect is good.

Early protective effect of ischemic preconditioning on small intestinal graft in rats

AIM: To investigate the early protective effect of ischemic preconditioning on small intestinal graft in rats.

METHODS: SD rats were randomly divided into the following groups: sham operation group (S group, n = 6), small bowel transplantation group (SBT group, n = 12), ischemic preconditioning plus small bowel transplantation group (ISBT group, n = 12). Heterotopic SBT was performed with a technique modified from that described by Monchik et al When the graft was revascularized successfully and reperfused for 1 h, samples were obtained from the different groups. Laminin was analyzed with immunohistochemical staining. Quantitative analysis of laminin positive signals was performed using image acquiring analysis system. Apoptotic epithelia of small intestinal graft were detected by the TdT-mediated dUTP nick end labeling method. The morphological change of epithelial basement membrane was observed by transmission electron microscopy.

RESULTS: The mean optical density value of laminin positive signals was 39.52 ± 2.60, 13.53 ± 0.44, 25.40 ± 1.79, respectively, in S, SBT and ISBT groups. The average optical density value of laminin positive products in SBT group was sharply lower than that in S group (P < 0.05). However, the mean optical density value of laminin positive products in ISBT group was significantly higher than that in SBT group (P < 0.05). The apoptotic index (AI) in S, SBT and ISBT group was 2.2 ± 0.83,30.8 ± 3.2, 13.2 ± 2.86, respectively. The AI in SBT group was significantly higher than that in S group (P < 0.05), and AI in ISBT group was sharply lower than that in SBT group (P < 0.05). On transmission electron microscopy, the epithelial basement membrane in S group stayed normal, but in SBT group it became disrupted and collapsed, even disappeared. The lesion of epithelial basement membrane in ISBT group was slighter compared with that in SBT group.

CONCLUSION: Ischemic preconditioning has an early protective effect on epithelial cells and extracellur matrix of small intestinal graft. Inhibition of epithelial cell apoptosis may be one of the mechanisms of ischemic preconditioning.

Serum growth factors and growth indices pre- and post-pediatric intestinal transplantation

BACKGROUND/PURPOSE

Although intestinal transplantation (ITx) has succeeded in liberating children with intestinal failure from total parenteral nutrition (TPN), positive growth has yet to be achieved in the majority of patients. This investigation aims to evaluate levels of serum growth factors as they relate to growth parameters and nutritional outcomes.

METHODS

Serum measures of insulin-like growth factor 1 (IGF-1) and insulin-like growth factor binding protein 3 (IGFBP-3) that had been obtained before and after transplantation were reviewed (with Institutional Review Board approval) in a subset of pediatric ITx recipients. Z-scores for weight and height were calculated at transplant and biannually thereafter for 2 years.

RESULTS

Five children received a small bowel/liver transplant between August 1996 and March 2000 (median age, 1.3 years). Before transplantation, levels of IGF-1 and IGFBP-3 were low in 60% and 67% of patients, respectively. Posttransplant levels of these growth factors were within normal limits or elevated in all but 2 patients (IGFBP-3 only). A positive trend in z-scores was observed in just one of 5 patients for weight and in 2 of 5 for height/length during the follow-up period. Of the 3 patients who experienced negative linear growth velocity over time, 2 had low pretransplant levels of both IGF-1 and IGFBP-3. All patients were weaned from TPN within 3 months after transplant.

CONCLUSIONS

Pretransplant levels of growth mediators may be predictive factors in children who will require an intensive regimen of nutritional rehabilitation posttransplant to promote the growth process. Absorption studies may aid in determining the appropriate nutrient substrates for the post-ITx population.

Update on management and treatment of short gut

Management of patients with short-bowel syndrome represents a formidable challenge. Aggressive treatment including nutritional care and anticipation of potential complications and rapid treatment of complications enhance outcome. New therapies offer the promise of significantly improving morbidity and mortality. Intestinal transplant is appropriate for infants who would otherwise die from liver disease, recurrent sepsis, or lack of venous access.

Ethical challenges in the care of infants with intestinal failure and lifelong total parenteral nutrition

Families, pediatric surgeons, and other care givers face difficult ethical challenges as they balance the benefits and burdens of total parenteral nutrition (TPN) and bowel transplantation in the face of uncertainty and the inability to predict which infants with intestinal failure are likely to have good outcomes. This article presents an analysis of 3 TPN cases using a comparison with dialysis and kidney transplantation, an older and more established technology for which ethical guidelines are proposed in the literature. The authors conclude that pediatric surgeons should recommend TPN in cases in which it is expected to be a temporary measure until bowel function is restored. TPN should not be recommended when other comorbidities make survival unlikely or when the infant is neurologically devastated. In the case of lifelong TPN in which bowel transplantation is only an option when TPN fails, pediatric surgeons should defer to parents in their choice about the use of lifelong TPN.