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Matsushima H, Sasaki K, Nair A, Tajima T, Soyama A, Eguchi S, Hashimoto K, Fujiki M. The impact of colonic allograft inclusion on intestinal transplantation outcomes: Results from UNOS/OPTN database analysis. Clin Transplant 2024; 38:e15213. [PMID: 38064299 DOI: 10.1111/ctr.15213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 11/15/2023] [Accepted: 11/17/2023] [Indexed: 01/31/2024]
Abstract
BACKGROUND Outcomes of intestinal transplantation with colon allograft (ICTx) remain controversial. We aimed to assess the outcomes of ICTx in comparison to intestinal transplantation without colon (ITx) using the UNOS/OPTN registry database. METHODS We retrospectively reviewed 2612 patients who received primary intestinal transplants from 1998 to 2020. The rates of acute rejection (AR) within 6 months after transplant were compared between ICTx and ITx. Risk factors of 6-month AR were examined using logistic regression model by era. Furthermore, conditional graft survival was analyzed to determine long-term outcomes of ICTx. RESULTS Of 2612 recipients, 506 (19.4%) received ICTx. Graft and patient survival in ICTx recipients were comparable to those in ITx recipients. White ICTx recipients had a higher incidence of AR within 6 months compared to ITx during the entire study period (p = .002), colonic inclusion did not increase the risk of 6-month AR in the past decade. ICTx recipients who experienced 6-month AR had worse graft and patient survival compared to those who did not (p <.001 and p = .004, respectively). Among patients who did not develop 6-month AR, Cox proportional hazard model analysis revealed that colonic inclusion was independently associated with improved conditional graft survival. CONCLUSIONS In the recent transplant era, colonic inclusion is no longer associated with a heightened risk of 6-month AR and may provide better long-term survival compared to ITx when AR is absent. Risk adjustment for rejection and proper immunosuppressive therapy are crucial to maximize the benefits of colonic inclusion.
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Affiliation(s)
- Hajime Matsushima
- Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kazunari Sasaki
- Division of Abdominal Transplant, Department of General Surgery, Stanford University Medical Center, Stanford, California, USA
| | - Amit Nair
- Department of Solid Organ Transplant Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Tetsuya Tajima
- Division of Abdominal Transplant, Department of General Surgery, Stanford University Medical Center, Stanford, California, USA
| | - Akihiko Soyama
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Koji Hashimoto
- Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Masato Fujiki
- Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Huard G, Schiano T, Moon J, Iyer K. Choice of Allograft in Patients Requiring Intestinal Transplantation: A Critical Review. Can J Gastroenterol Hepatol 2017; 2017:1069726. [PMID: 28553630 DOI: 10.1155/2017/1069726] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 04/05/2017] [Indexed: 02/06/2023] Open
Abstract
Intestinal transplantation (ITx) is indicated in patients with irreversible intestinal failure (IF) and life-threatening complications related to total parenteral nutrition (TPN). ITx can be classified into three main types. Isolated intestinal transplantation (IITx), that is, transplantation of the jejunoileum, is indicated in patients with preserved liver function. Combined liver-intestine transplantation (L-ITx), that is, transplantation of the liver and the jejunoileum, is indicated in patients with liver failure related to TPN. Thus, patients with cirrhosis or advanced fibrosis should receive a combined allograft, while patients with lower grades of liver fibrosis can usually safely undergo ITx. Reflecting their degree of sickness, the waitlist mortality rate and the early posttransplant outcomes of patients receiving L-ITx are worse than IITx. However, L-ITx is associated with better long-term graft and patient survival. Multivisceral transplantation (MVTx), that is, transplantation of the organs dependent on the celiac axis and superior mesenteric artery, can be classified into full MVTx if it includes the liver and modified MVTx if it does not. The most common indications for MVTx are extensive portomesenteric thrombosis and diffuse gastrointestinal pathology such as motility disorders and polyposis syndrome. Every patient with IF should undergo a multidisciplinary evaluation by an experienced ITx team.
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Huard G, Schiano T, Fiel MI, Ward SC, Moon J, Iyer K. Comparative incidence of rejection occurring in small intestinal and colonic mucosal biopsies of patients undergoing intestinal transplantation. Histopathology 2016; 69:600-6. [DOI: 10.1111/his.12982] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 04/06/2016] [Indexed: 12/01/2022]
Affiliation(s)
- Geneviève Huard
- Intestinal Transplant Program; Recanati Miller Transplant Institute; The Mount Sinai Hospital; New York NY USA
- Department of Medicine; Liver Unit; Centre Hospitalier de l'Université de Montréal; Montreal QC Canada
| | - Thomas Schiano
- Intestinal Transplant Program; Recanati Miller Transplant Institute; The Mount Sinai Hospital; New York NY USA
| | - Marie I Fiel
- Department of Pathology; Division of GI Pathology; The Mount Sinai Hospital; New York NY USA
| | - Stephen C Ward
- Department of Pathology; Division of GI Pathology; The Mount Sinai Hospital; New York NY USA
| | - Jang Moon
- Intestinal Transplant Program; Recanati Miller Transplant Institute; The Mount Sinai Hospital; New York NY USA
| | - Kishore Iyer
- Intestinal Transplant Program; Recanati Miller Transplant Institute; The Mount Sinai Hospital; New York NY USA
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Abstract
Intestinal transplantation has now emerged as a lifesaving therapeutic option and standard of care for patients with irreversible intestinal failure. Improvement in survival over the years has justified expansion of the indications for intestinal transplantation beyond the original indications approved by Center for Medicare and Medicaid services. Management of patients with intestinal failure is complex and requires a multidisciplinary approach to accurately select candidates who would benefit from rehabilitation versus transplantation. Significant strides have been made in patient and graft survival with several advancements in the perioperative management through timely referral, improved patient selection, refinement in the surgical techniques and better understanding of the immunopathology of intestinal transplantation. The therapeutic efficacy of the procedure is well evident from continuous improvements in functional status, quality of life and cost-effectiveness of the procedure. This current review summarizes various aspects including current practices and evidence based recommendations of intestinal transplantation.
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Affiliation(s)
- Aparna Rege
- Department of Surgery, Division of Abdominal Transplantation, Duke University Medical Center, Durham, NC, USA.
| | - Debra Sudan
- Department of Surgery, Division of Abdominal Transplantation, Duke University Medical Center, Durham, NC, USA
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Grant D, Abu-Elmagd K, Mazariegos G, Vianna R, Langnas A, Mangus R, Farmer DG, Lacaille F, Iyer K, Fishbein T. Intestinal transplant registry report: global activity and trends. Am J Transplant 2015; 15:210-9. [PMID: 25438622 DOI: 10.1111/ajt.12979] [Citation(s) in RCA: 270] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 07/16/2014] [Accepted: 08/12/2014] [Indexed: 01/25/2023]
Abstract
The Registry has gathered information on intestine transplantation (IT) since 1985. During this time, individual centers have reported progress but small case volumes potentially limit the generalizability of this information. The present study was undertaken to examine recent global IT activity. Activity was assessed with descriptive statistics, Kaplan-Meier survival curves and a multiple variable analysis. Eighty-two programs reported 2887 transplants in 2699 patients. Regional practices and outcomes are now similar worldwide. Current actuarial patient survival rates are 76%, 56% and 43% at 1, 5 and 10 years, respectively. Rates of graft loss beyond 1 year have not improved. Grafts that included a colon segment had better function. Waiting at home for IT, the use of induction immune-suppression therapy, inclusion of a liver component and maintenance therapy with rapamycin were associated with better graft survival. Outcomes of IT have modestly improved over the past decade. Case volumes have recently declined. Identifying the root reasons for late graft loss is difficult due to the low case volumes at most centers. The high participation rate in the Registry provides unique opportunities to study these issues.
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Affiliation(s)
- D Grant
- Department of Surgery, University Health Network, Toronto, Canada
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Nickkholgh A, Contin P, Abu-Elmagd K, Golriz M, Gotthardt D, Morath C, Schemmer P, Mehrabi A. Intestinal transplantation: review of operative techniques. Clin Transplant 2014; 27 Suppl 25:56-65. [PMID: 23909503 DOI: 10.1111/ctr.12190] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2013] [Indexed: 01/01/2023]
Abstract
The improvement of outcomes in intestinal transplantation (ITx) over the last two decades has been made possible through standardization in surgical techniques, improvements in immunosuppressive and induction protocols, and post-operative patient care. From a surgical technical point of view, all different types of small bowel containing transplants can be categorized into three main prototypes, including isolated small bowel, liver-small bowel, and multivisceral transplantations. In this review, we describe these three main prototypes and discuss the most important technical modifications of each type, as well as donor and recipient procedures, and highlight the more recent operative technical topics of discussion in the literature.
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Affiliation(s)
- Arash Nickkholgh
- Department of General, Visceral and Transplantation Surgery, Ruprecht-Karls University, Heidelberg, Germany
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Fischer-Fröhlich CL, Königsrainer A, Schaffer R, Schaub F, Pratschke J, Pascher A, Steurer W, Nadalin S. Organ donation: when should we consider intestinal donation. Transpl Int 2012; 25:1229-40. [DOI: 10.1111/j.1432-2277.2012.01556.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Beuk RJ, Tangelder GJ, Maassen RLJG, Quaedackers JSLT, Heineman E, oude Egbrink MGA. Leucocyte and platelet adhesion in different layers of the small bowel during experimental total warm ischaemia and reperfusion. Br J Surg 2008; 95:1294-304. [DOI: 10.1002/bjs.6320] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Abstract
Background
Ischaemia and reperfusion (IR) of the small bowel is involved in many clinical conditions. A key component in IR-induced tissue damage is microvascular dysfunction. The aim was to investigate the role of leucocytes and platelets in capillary flow impediment and tissue damage.
Methods
Anaesthetized rats were subjected to 30 min warm ischaemia of the small bowel, followed by 1 h reperfusion. To elucidate the influence of leucocytes on platelet adhesion, leucocyte–vessel wall interactions induced by IR were prevented by anti-platelet activating factor (PAF) or anti-intercellular adhesion molecule (ICAM)-1. Intravital videomicroscopy was performed and tissue injury was evaluated histologically.
Results
In submucosal venules, IR induced an increase in the median number of interacting leucocytes from 3 to 10 and 20 leucocytes per 100-µm venule segment after 10 and 60 min reperfusion respectively. Anti-PAF or anti-ICAM-1 completely attenuated this increase, resulting in an eightfold improvement in submucosal capillary flow and reduced tissue injury. Shedding of villi no longer occurred. Platelet–vessel wall interactions occurred particularly in submucosal venules, but were not affected by anti-PAF or anti-ICAM-1.
Conclusion
Small bowel IR initiated an inflammatory and thrombotic response in the submucosal layer only. Attenuation of leucocyte adhesion improved submucosal capillary perfusion, preventing shedding of mucosal villi.
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Affiliation(s)
- R J Beuk
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - G-J Tangelder
- Laboratory for Physiology, Institute for Cardiovascular Research, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - R L J G Maassen
- Department of Surgery, Cardiovascular Research Institute Maastricht, University Hospital Maastricht, Maastricht, The Netherlands
| | - J S L T Quaedackers
- Department of Surgery, Cardiovascular Research Institute Maastricht, University Hospital Maastricht, Maastricht, The Netherlands
| | - E Heineman
- Department of Surgery, Cardiovascular Research Institute Maastricht, University Hospital Maastricht, Maastricht, The Netherlands
| | - M G A oude Egbrink
- Department of Physiology, Cardiovascular Research Institute Maastricht, University Hospital Maastricht, Maastricht, The Netherlands
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Abstract
Even though surgical techniques for isolated intestine, liver-intestine, and multivisceral transplantations were developed in the 1960's, very few patients were transplanted before 1990 because initial immunosuppression regimens were insufficient, making intestine transplantation impossible. Intestine transplantation resulted in death in most patients within days or months. The discouraging results of the first clinical trials were due to technical complications, sepsis, and the failure of conventional immunosuppression to control rejection. By 1990 the development of tacrolimus-based immunosuppression and improved surgical techniques, the increased array of potent immunosuppressive medications, infection prophylaxis, and suitable patient selection helped improve actuarial graft and patient survival rates for all types of intestine transplantation. The aims of this review are to describe the current status of intestine transplantation including the underlying diseases and conditions that may be indications for intestine transplantation, to identify patient populations for this indication, to provide key steps for patient evaluation, to summarize current recommendations for immunosuppression, to list the most common postoperative complications, and to discuss the international experience of small bowel transplantation compiled and analyzed by the International Intestine Transplant Registry since 1985.
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Affiliation(s)
- Thierry Yandza
- Service de Chirurgie Viscérale et de Transplantation Hépatique, Hôpital de L'Archet II, Centre Hospitalo-Universitaire de Nice, Nice, France.
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Jugie M, Canioni D, Le Bihan C, Sarnacki S, Revillon Y, Jan D, Lacaille F, Cerf-Bensussan N, Goulet O, Brousse N, Damotte D. Study of the impact of liver transplantation on the outcome of intestinal grafts in children. Transplantation 2006; 81:992-7. [PMID: 16612274 DOI: 10.1097/01.tp.0000195899.32734.83] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Successful small bowel transplantation remains a challenge due to the septic and immune content of the gut. The possible beneficial role of the liver was assessed in pediatric recipients of isolated intestinal and liver intestinal combined transplantation, receiving the same immunosuppressive therapy. METHODS Fifteen children who underwent small bowel transplantation (seven SbTx) or combined liver-small bowel transplantation (eight LSbTx) at a single center between 1994 and 1998 were retrospectively reviewed and compared with fifteen controls (eight normal and seven appendicitis as inflammatory control). Transplant and patient survival, acute rejection episodes were analyzed and compared. Epithelial apoptotic body counts (ABC) and NF-kB (p65), Caspase-3 and Bax intestinal immunostaining from days 0 to 20 after transplantation were assessed. RESULTS Graft and patient survivals at 5 years were respectively 75% and 75% in LSbTx; 43% and 57% in SbTx (NS). Histological analysis showed higher ABC in LSbTx intestinal mucosa (P = 0.05 on day 5, P < 0.01 thereafter). Immunostaining of biopsies on day 0 after reperfusion showed different expression of NF-kB, Caspase-3 and Bax on endothelial (P < 0.05 for NF-kB and Bax), mononuclear (P < 0.05 for Bax) and epithelial cells in LSbTx and SbTx. CONCLUSIONS Our results suggest a protective role of the liver toward intestinal transplantation even in absence of significative difference, probably due to the small number of children. Early changes in NF-kB immunostaining in the biopsies sampled on day 0, pointed to a possible beneficial effect of the liver in the very early phase following transplantation, perhaps through the differential control of ischemia-reperfusion.
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Affiliation(s)
- Myriam Jugie
- Pediatrics Department, Saint-Vincent-de-Paul Hospital, Necker-Enfants Malades Hospital, Paris, France
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14
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Abstract
Advances in immunosuppressive treatment as well as better monitoring and control of acute rejection have brought intestinal transplantation (ITx) into the realm of standard treatment for permanent intestinal failure. The results from the intestinal Transplant International Registry (www.intestinaltransplant.org) indicate that ITx is currently an acceptable clinical modality for selected patients with permanent intestinal failure. The goal of this short review is to deal with indications, clinical results and complications of ITx. Although it has been used in humans for the past two decades, very few data are available regarding graft function and its monitoring.
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Affiliation(s)
- Olivier Goulet
- Combined Programme of Intestinal Transplantation Hôspital Necker-Enfants Malades, Paris, France.
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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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