Intestinal Transplantation Treatment & Management

  • Author: Stuart M Greenstein, MD; Chief Editor: Mary C Mancini, MD, PhD   more...
 
Updated: Mar 5, 2012
 

Surgical Therapy

The basic steps of the procurement of an isolated small bowel graft are as follows:

  • Although some transplant programs perform a decontamination of the donor bowel via a nasogastric tube, this is not uniformly performed.
  • Immunosuppression is given to the donor by some transplant programs just before or at the time of the procurement. Antithymocyte globulin, muromonab, basiliximab, and steroids are most frequently used.
  • University of Wisconsin Universal Organ Preservation (UW) solution for both in situ flushing and cold storage is most frequently used.
  • Obtain wide exposure to the abdominal cavity and encircle the abdominal aorta distally for subsequent insertion of the infusion cannula and proximally above the celiac axis for cross-clamping.
  • Perform dissection, in situ cooling of abdominal organs, and exsanguination before removing the organs to the back table for preparation.
  • Detach the small bowel from the large bowel by total colectomy.
  • Mobilize and devascularize the cecum and ascending colon, with care to preserve the ileal branches of the ileocolic artery.
  • Divide and close the ileum with a GIA stapler near the ileocecal valve.
  • Devascularize the colon by ligating and dividing the middle colic, left colic, and inferior mesenteric arteries near their origin.
  • After transection of the gastrocolic ligament and transection of the stapled sigmoid colon, remove the large bowel and greater omentum.
  • Free the root of the small bowel mesentery from its retroperitoneal attachments.
  • Expose the mesenteric root, abdominal aorta, and infrahepatic vena cava, including entry of the renal veins.
  • Divide the highest jejunal vascular arcades.
  • Preserve the vascular supply to the fourth part of the duodenum and the proximal part of the jejunum.
  • Transect the proximal jejunum after mobilizing and dividing the ligament of Treitz and the inferior mesenteric vein (IMV).
  • At this stage, the intestine is attached to the donor only by the superior mesenteric pedicle, containing the superior mesenteric artery and superior mesenteric vein.
  • Divide the mesenteric root distal to the level of the ligated middle colic vessel.
  • Transaortic cooling requires UW solution (50-100 mL/kg) for pediatric donors.
  • Vent venous beds via the suprahepatic vena cava.
  • Avoid overperfusion of the intestine.
  • Remove the small-intestine graft by dissection of the superior mesenteric artery and superior mesenteric vein below the origin of the inferior pancreaticoduodenal artery.
  • Excise a large Carrel patch from the anterior aortic wall containing the celiac axis and superior mesenteric artery.
  • Procure iliac and carotid arteries and veins as potential vascular grafts.

Back-table preparation of organs

  • Small-intestine grafts require little revision.
  • If the pedicle of the superior mesenteric artery is too short, it may be lengthened with free vascular grafts.
  • Identify and tie lymphatics.
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Intraoperative Details

  • The intestinal graft implantation begins with the take down of adhesions, which are usually abundant in these patients secondary to previous surgeries.
  • The aorta and cava are dissected in preparation for the vascular anastomosis.
  • The proximal and distal ends of the remnant digestive track are dissected free.
  • Venous anastomosis to the graft is usually performed to the recipient cava.
  • Arterial anastomosis is performed to the abdominal aorta.
  • After reperfusion of the graft and profuse hemostasia, the proximal and distal end of the intestinal graft is anastomosed to the proximal and distal ends of the remnant digestive track.
  • A loop ileostomy is created for future endoscopic surveillance.
  • The closure of the abdominal wall can be another challenging part of the procedure, especially considering that these pediatric patients are often small.
  • Do not risk the perfusion of the graft by attempting a closure under tension. If this is the case, keeping the abdominal wall open and planning for a sequential closing is preferable.
  • In special situations, transplantation of the abdominal wall from the same deceased donor can be intended. See the image below.Isolated intestinal transplant. A gastrostomy tubeIsolated intestinal transplant. A gastrostomy tube, jejunostomy tube, and loop ileostomy are in place.
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Postoperative Details

  • Patients require ICU monitoring postoperatively.
  • Induction therapy with monoclonal (alemtuzumab, basiliximab, daclizumab) or polyclonal (Thymoglobulin) antibody preparations is often administered intraoperatively or preoperatively in the recipient. Immunosuppressive practices have changed significantly in the last years. Use of any induction therapy was uncommon in 1997. By 2000, 69% of transplant recipients reported using induction therapy; daclizumab was the most commonly used induction agent. In 2003, the most common agent was rabbit antithymocyte globulin, with 46% using this agent. By 2006, induction therapy was evenly distributed among muromonab-CD3 (14%), rabbit antithymocyte globulin (18%), daclizumab (17%), and alemtuzumab (21%).
  • Tacrolimus via enteric administration and intravenous steroids are typically begun immediately after the surgery and are maintained at discharge.
  • High levels of immunosuppression are maintained early in the postoperative period (tacrolimus levels, 20-25 ng/mL).
  • Consider the variable absorption and bioavailability of whichever immunosuppression regimen is used (ie, tacrolimus, cyclosporine microemulsion). Because the bioavailability of these drugs depends on intestinal surface area and transit time, the function of the grafts directly affects drug availability.
  • Mycophenolate mofetil is often avoided because of its association with GI side effects.
  • Sirolimus is use in combination with tacrolimus by some programs.
  • Prostaglandin E1 is intravenously administered for the first 5-10 days posttransplant because of its ability to improve the small bowel microcirculation and its potential immunosuppressive effects.
  • Broad-spectrum intravenous antibiotics are administered for about 1 week after the transplant.
  • Check laboratory findings regularly for evidence of bleeding.
  • Monitor serum pH and lactate levels to detect any evidence of intestinal ischemia.
  • When GI function is re-established, as indicated by decreasing G-tube returns and increasing gas and enteric contents in the ileostomy, a diet can be initiated and cautiously advanced as tolerated to provide full nutritional support. To avoid the development of chylous ascites, a consequence of the graft's severed lymphatics during the procurement, a no-fat or low-fact diet can be initially used.
  • Initiate appropriate antiviral prophylaxis with ganciclovir and/or cytomegalovirus (CMV) immunoglobulin (CytoGam).
  • At regular intervals, perform CMV antigenemia, quantitative Epstein-Barr virus (EBV) polymerase chain reaction (PCR) surveillance,[10] routine cultures, transplant ileostomal endoscopy, and biopsy. Additionally, monitor fluid status, stool losses, and serum electrolytes.
  • The transplanted intestine initiates peristalsis immediately after reperfusion but in a less orderly fashion secondary to the extrinsic innervation being disrupted during the procurement. The dysfunctional residual native intestine, stomach or colon in a patient with a primary dysmotility syndrome could aggravate this problem.
  • The carbohydrates and amino acid absorptive capacity of the transplanted intestine normalize within the first several months. Fat absorption is impaired for several months following intestinal transplantation. Absorption of dietary lipids, which are primarily composed of long-chain triglycerides, depends on lymphatic drainage. Medium-chain triglycerides can be directly absorbed into the portal circulation. For these reasons, supplementing enteral feeds with medium-chain triglycerides for several months following transplantation is necessary. Intermittently supplementing the diet with intravenous fats and fat-soluble vitamins (vitamin D, E, A, and K) may be necessary until the intestinal lymphatics are reestablished.
  • Once enteral nutrition is providing all nutritional requirements, total parenteral nutrition (TPN) can be discontinued.
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Complications

Infectious complications account for approximately 60% of intestinal graft losses, with rejection and technical errors accounting for a further 36%. An autopsy series found 94% of patients had a coexisting infection, even in cases in which sepsis was not the immediate cause of death. Posttransplant lymphoproliferative disease (PTLD) and graft rejection can lead to breakdown of the mucosal barrier, resulting in bacteremia or fungemia.

Infection

Patients undergoing intestinal transplant have a higher incidence of infectious complication than other transplant recipients. This is secondary to the very high load of microorganism that the intestinal graft posses and because these patients are maintained on higher degrees of immunosuppression than recipients of other organ transplants.[11]

Bacterial infections

The bacteria from the intestinal graft can infect the transplanted patient via two routes. The lymphatics that were divided in the procurement are a source of leakage of intestinal lymph into the peritoneal cavity. This lymph contains bacteria and can lead to bacterial peritonitis in the immunosuppressed patient. The second route is by direct translocation into the portal circulation and subsequent dissemination to other sites. The most common organisms include Escherichia coli, Klebsiella, Enterobacter, staphylococci, and Enterococcus.

Viral infections

Cytomegalovirus (CMV) infection reportedly occurs in 15-30% of patients receiving intestinal grafts and most often involves an allograft intestine. CMV disease is one of the most serious infections that can occur after a transplant because it can lead to loss of the transplanted organ and even death. Incidence of CMV disease is highest in CMV-negative recipients who receive CMV-positive grafts. As a result, transplantation of isolated intestines from CMV-positive donors to CMV-negative recipients is often avoided.

Patients with CMV enteritis usually present with fever, increased stomal output, GI symptoms, decreased WBC count, and flulike symptoms. Infection is diagnosed by measuring CMV antigenemia and by endoscopic examination findings. Endoscopy reveals superficial ulcers, and histopathology confirms CMV inclusion bodies. If CMV is diagnosed, the patient should be treated with therapeutic doses of ganciclovir. Foscarnet or CMV immunoglobulin (CytoGam) should be considered in case of ganciclovir resistance. Immunosuppression should be reduced until the CMV infection is controlled but should not be discontinued to avoid breakthrough rejection.

Epstein-Barr virus is also a concern. The risk is higher in EBV-negative recipients who receive an EBV-positive graft. An acute EBV virus infection is typically associated with severe malaise and fever, flulike symptoms, increase of liver function tests, splenomegaly, and lymphadenopathy.

The biggest concern is the development of PTLD. The incidence of PTLD is higher in intestinal transplant recipients than any other solid organ transplant recipients. It occurs more often in children than in adults, and the incidence is higher after multivisceral transplantation than after isolated intestinal transplantation. Although PTLD tends first to manifest between 2 weeks and 6 months after a transplant, it can appear at any time.

Surveillance for PTLD should begin immediately following the transplant using in situ hybridization staining for EBV and early RNA and EBV polymerase chain reaction (PCR) surveillance. Two basic approaches are used to prevent PTLD. One is long-term prophylaxis with ganciclovir or intravenous immunoglobulin for 3-12 months. The other involves a shorter period of prophylaxis (2–6 wk) followed by surveillance and preemptive therapy should surveillance identify increased EBV replication.

The diagnosis of PTLD usually requires a biopsy. Often, this is most easily obtained from an enlarged superficial lymph node or from clinically or radiologically involved tissue. If the suspected organ is the intestine graft itself, differentiating PTLD from rejection or CMV infection can be difficult. Evaluating the serum for a typical monoclonal or polyclonal immunoglobulin band, which can sometimes be present, is also useful. Gene studies are often helpful to identify abnormal karyotypes (eg, C-myc, N-ras, p53), which can aid in diagnosis and prognosis. Determine whether the abnormal lymphocytes sites are primarily B cells or T cells. T-cell lymphomas are less common than B-cell lymphomas in PTLDs.

If the diagnosis of PTLD is made, immunosuppression should be reduced to approximately half of what it had been. In approximately one third of cases, this results in a remission of the PTLD. If improvement is not evident after 2 weeks, all immunosuppression should be discontinued and serious consideration should be given to additional therapeutic measures, including chemotherapy, monoclonal antibody administration, or adoptive immunotherapy. If necessary, an intestine-only graft can also be removed.

Rejection

Rejection can occur at any time but is most common in the first year, particularly the first 6 months. Early diagnosis of allograft rejection, a major contributor to both the high morbidity and the high mortality associated with small-intestine transplantation, is essential. Intestinal graft rejection manifests itself clinically as fever, abdominal pain, increased output from the ostomy, abdominal distention, and acidosis. Malabsorption and electrolyte abnormalities occur in some patients. It can also be asymptomatic.

No blood test reliably detects early rejection. Several markers have been studied as indicators of rejection (eg, calprotectin, citrulline, granzyme B, perforin) but are still considered experimental. Therefore, surveillance via endoscopy (especially zoom videoendoscopy) and intestinal biopsy through the ileostomy are used. Diagnosis can be difficult because of the patchy nature of rejection and the presence of bleeding. Therefore, the endoscopy should include as much of the small bowel as possible, and biopsies from numerous sites should be obtained. Although evidence of inflammation and ulceration is usually present, endoscopic appearance of the graft can be quite normal in early rejection.

Histologic evidence of allograft rejection includes mucosal necrosis and loss of villous architecture with transmural cellular infiltrate. Histopathology reveals crypt cell apoptosis, cryptitis or crypt loss, necrosis, and endotheliitis.

Rejection may be treated by an intravenous bolus of methylprednisolone (10 mg/kg), followed by steroid recycle and optimization of the tacrolimus level. Antithymocyte globulin or muromonab may be used to treat steroid-resistant rejection.

Some centers have reported that combined liver-intestine transplantation provides a greater protective benefit (ie, lower incidence and severity of acute rejection) than isolated intestinal transplantation.

Graft Versus Host Disease

The small intestine is an immunocompetent organ; its population of lymphoid cells can mount an immunologic response to the host (ie, a graft versus host disease [GVHD] reaction. GVHD may be subclinically manifested and diagnosed only histologically. Patients with acute GVHD usually present 1-8 weeks after transplantation with fever, leukopenia, diarrhea, and rash. Other symptoms may include malaise, anorexia, arthralgia, and abdominal pain. Diagnosis should be confirmed by biopsy of the skin or bowel. Once diagnosis is confirmed, promptly institute treatment with high-dose steroids and antithrombocyte globulin or with OKT3.

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Outcome and Prognosis

Survival after intestinal transplantation has shown steady improvement over the last decade. The 1-year adjusted graft survival increased from 52 ± 6.3% in 1997 to 75 ± 3.4% in 2005. Similarly, the 1-year adjusted patient survival improved from 57 ± 6.5% in 1997 to 80 ± 3.3% in 2005. When analyzing the results for intestinal transplantation, separating results of intestine alone transplants and liver-intestine transplants is essential.

For recipients of intestine alone, unadjusted patient survival is 81% for 1 year, 67% for 3 years, 54% for 5 years, and 43% for 10 years. Graft survival during the same intervals is 73%, 54%, 37%, and 23%, respectively. Patient survival for recipients of liver-intestine transplants is 76% for 1 year, 70% for 3 years, 58% for 5 years, and 38% for 10 years. Intestine graft survival for the same intervals is 75%, 69%, 56%, and 36%, respectively.

Morbidity is as follows:

  • Acute rejection
    • Intestine-only transplant - 79%
    • Liver-intestine transplant - 71%
    • Multivisceral transplant - 56%
  • Chronic rejection
    • Intestine-only transplant - 13%
    • Liver-intestine transplant - 3%
    • Multivisceral transplant - 0%
  • Cytomegalovirus (CMV) infection
    • Intestine-only transplant - 24%
    • Liver-intestine transplant - 18%
    • Multivisceral transplant - 40%
  • Posttransplant lymphoproliferative disease (PTLD)
    • Intestine-only transplant - 7%
    • Liver-intestine transplant - 11%
    • Multivisceral transplant - 13%

Mortality is as follows:

  • Sepsis
    • Intestinal transplant deaths clearly attributed to sepsis - 47%
    • Multiorgan failure deaths in which sepsis was a likely contributing factor - 26%
  • Graft thrombosis deaths - 10%
  • PTLD deaths - 10%
  • Rejection deaths - 4%
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Future and Controversies

The number of intestinal transplants performed has been consistently growing and is expected to increase. From 1997-2006, the number of isolated intestinal transplants increased 171%. During the same period, the number of multiorgan transplants increased 187%; organ combinations that included the intestine were the second most common after liver-kidney transplant. At the same time, survival rates are improving and are getting very close to what is seen after liver transplantation.

Still, major issues remain, such as the extremely high mortality in patients on the waiting list and the organ shortage. Another issue is the difficult balance between appropriate immunosuppression in order to avoid rejection and overimmunosuppression with its devastating complications. This issue makes the development of markers to detect early rejection imperative.[12]

Many efforts have been placed in techniques to induce a state of microchimerism and tolerance by transplanting bone marrow along with the intestinal allograft. This ongoing research may change the future of transplantation of the small bowel and other organs.

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Contributor Information and Disclosures
Author

Stuart M Greenstein, MD  Professor of Surgery, Albert Einstein College of Medicine; Consulting Surgeon, Department of Surgery, Division of Transplantation, Montefiore Medical Center

Stuart M Greenstein, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Society of Transplant Surgeons, American Society of Transplantation, Association for Academic Surgery, International College of Surgeons, Medical Society of New Jersey, National Kidney Foundation, New York Academy of Sciences, and Southeastern Surgical Congress

Disclosure: Nothing to disclose.

Coauthor(s)

Javier Chapochnhick Friedmann, MD  Multiorgan Transplant Surgeon, Department of Surgery, Division of Transplantation, Montefiore Medical Center; Assistant Professor of Surgery, Albert Einstein College of Medicine

Javier Chapochnhick Friedmann, MD is a member of the following medical societies: American Hepato-Pancreato-Biliary Association, American Society of Transplant Surgeons, International Hepato-Pancreato-Biliary Association, International Liver Transplantation Society, International Pediatric Transplant Association, and Transplantation Society

Disclosure: Nothing to disclose.

Owen Prowse, MD, MPH, FRCSC  Assistant Professor, Department of Surgery, Northern Ontario School of Medicine, Lakehead University and Laurentian University

Owen Prowse, MD, MPH, FRCSC is a member of the following medical societies: Canadian Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Casimir F Firlit, MD, PhD  Director of Reconstructive Urology, Department of Neuro-Urology and Fetal Urology, SSM Cardinal Glennon Children's Medical Center

Casimir F Firlit, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Society of Transplant Surgeons, American Urological Association, and Illinois State Medical Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Steve Dunn, MD  Chief, Solid Organ Transplantation, Department of Surgery, Alfred I DuPont Hospital for Children at Wilmington

Steve Dunn, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society of Transplant Surgeons, American Society of Transplantation, and Christian Medical & Dental Society

Disclosure: Nothing to disclose.

Ron Shapiro, MD  Professor of Surgery, Robert J Corry Chair in Transplantation Surgery, Director, Kidney, Pancreas, and Islet Transplantation, Thomas E Starzl Transplantation Institute, University of Pittsburgh Medical Center

Ron Shapiro, MD is a member of the following medical societies: American College of Surgeons, American Society of Transplant Surgeons, Association for Academic Surgery, Central Surgical Association, and Society of University Surgeons

Disclosure: Brystol Meyer Squibb StemCell Data Monitoring Committee Consulting fee Review panel membership; Stem Cells, Inc Consulting fee Review panel membership; Up To Date contracted Author; Novartis Honoraria Consulting; Genentech/Valcyte Honoraria Consulting

Chief Editor

Mary C Mancini, MD, PhD  Professor and Chief of Cardiothoracic Surgery, Department of Surgery, Louisiana State University School of Medicine in Shreveport

Mary C Mancini, MD, PhD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Phi Beta Kappa, Society of Thoracic Surgeons, and Southern Surgical Association

Disclosure: Nothing to disclose.

References

  1. Bueno J, Ohwada S, Kocoshis S. Factors impacting the survival of children with intestinal failure referred for intestinal transplantation. J Pediatr Surg. Jan 1999;34(1):27-32; discussion 32-3. [Medline].

  2. Carrel A. La technique des anastomese vasculaires et la transplantation des visceres. Lyon Med. 1902;98:859.

  3. Lee RG, Nakamura K, Tsamandas AC, et al. Pathology of human intestinal transplantation. Gastroenterology. Jun 1996;110(6):1820-34. [Medline].

  4. Lillehei RC, Goott B, Miller FA. The physiological response of the small bowel of the dog to ischemia including prolonged in vitro preservation of the bowel with successful replacement and survival. Ann Surg. Oct 1959;150:543-60. [Medline]. [Full Text].

  5. de Serre NP, Canioni D, Lacaille F, et al. Evaluation of c4d deposition and circulating antibody in small bowel transplantation. Am J Transplant. Jun 2008;8(6):1290-6. [Medline].

  6. Goulet O, Revillon Y, Jan D. Small-bowel transplantation in children. Transplant Proc. Dec 1990;22(6):2499-500. [Medline].

  7. Grant D, Abu-Elmagd K, Reyes J, Tzakis A, Langnas A, Fishbein T, et al. 2003 report of the intestine transplant registry: a new era has dawned. Ann Surg. Apr 2005;241(4):607-13. [Medline]. [Full Text].

  8. Grant D, Lamont D, Zhong R, et al. 51Cr-EDTA: a marker of early intestinal rejection in the rat. J Surg Res. May 1989;46(5):507-14. [Medline].

  9. Matsusaki T, Sakai T, Boucek CD, Abu-Elmagd K, Martin LM, Amesur N, et al. Central venous thrombosis and perioperative vascular access in adult intestinal transplantation. Br J Anaesth. Feb 23 2012;[Medline].

  10. Li Q, Wang C, Zhang Q, Tang C, Li N, Ruan B, et al. Use of 18S ribosomal DNA polymerase chain reaction-denaturing gradient gel electrophoresis to study composition of fungal community in 2 patients with intestinal transplants. Hum Pathol. Feb 1 2012;[Medline].

  11. 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. Oct 9 2011;[Medline].

  12. Andreev VP, Tryphonopoulos P, Blomberg BB, Tsinoremas N, Weppler D, Neuman DR, et al. Peripheral blood gene expression analysis in intestinal transplantation: a feasibility study for detecting novel candidate biomarkers of graft rejection. Transplantation. Dec 27 2011;92(12):1385-91. [Medline].

  13. Abu-Elmagd K, Fung J, Bueno J, Martin D, Madariaga JR, Mazariegos G, et al. Logistics and technique for procurement of intestinal, pancreatic, and hepatic grafts from the same donor. Ann Surg. Nov 2000;232(5):680-7. [Medline]. [Full Text].

  14. Beath SV, Protheroe SP, Brook GA. Early experience of paediatric intestinal transplantation in the United Kingdom, 1993 to 1999. Transplant Proc. Sep 2000;32(6):1225. [Medline].

  15. Benedetti E, Baum C, Raofi V. Living related small bowel transplantation: progressive functional adaptation of the graft. Transplant Proc. Sep 2000;32(6):1209. [Medline].

  16. Benedetti E, Holterman M, Asolati M, Di Domenico S, Oberholzer J, Sankary H, et al. Living related segmental bowel transplantation: from experimental to standardized procedure. Ann Surg. Nov 2006;244(5):694-9. [Medline]. [Full Text].

  17. Bradley SP, Banner B, Elias G, et al. Genetic expression profile during acute cellular rejection in clinical intestinal transplantation. Transplantation. Oct 15 2008;86(7):998-1001. [Medline].

  18. Buchholz BM, Kaczorowski DJ, Sugimoto R, et al. Hydrogen inhalation ameliorates oxidative stress in transplantation induced intestinal graft injury. Am J Transplant. Oct 2008;8(10):2015-24. [Medline].

  19. Buchman AL, Iyer K, Fryer J. Parenteral nutrition-associated liver disease and the role for isolated intestine and intestine/liver transplantation. Hepatology. Jan 2006;43(1):9-19. [Medline].

  20. Bueno J, Green M, Kocoshis S, et al. Cytomegalovirus infection after intestinal transplantation in children. Clin Infect Dis. Nov 1997;25(5):1078-83. [Medline].

  21. Carrel A. The transplantation of organs: a preliminary communication. JAMA. 1905;45:1645.

  22. Cavicchi M, Beau P, Crenn P, Degott C, Messing B. Prevalence of liver disease and contributing factors in patients receiving home parenteral nutrition for permanent intestinal failure. Ann Intern Med. Apr 4 2000;132(7):525-32. [Medline].

  23. Chan S, McCowen KC, Bistrian BR, et al. Incidence, prognosis, and etiology of end-stage liver disease in patients receiving home total parenteral nutrition. Surgery. Jul 1999;126(1):28-34. [Medline].

  24. Chungfat N, Dixler I, Cohran V, Buchman A, Abecassis M, Fryer J. Impact of parenteral nutrition-associated liver disease on intestinal transplant waitlist dynamics. J Am Coll Surg. Dec 2007;205(6):755-61. [Medline].

  25. Cicalese L, Sileri P, Green M. Bacterial translocation in clinical intestinal transplantation. Transplant Proc. Sep 2000;32(6):1210. [Medline].

  26. D'Alessandro AM, Kalayoglu M, Hammes R, et al. Diagnosis of intestinal transplant rejection using technetium-99m-DTPA. Transplantation. Jul 15 1994;58(1):112-3. [Medline].

  27. David AI, Selvaggi G, Ruiz P, et al. Blood citrulline level is an exclusionary marker for significant acute rejection after intestinal transplantation. Transplantation. Nov 15 2007;84(9):1077-81. [Medline].

  28. Deltz E, Schroeder P, Gebhardt H. [First successful clinical small intestine transplantation. Tactics and surgical technic]. Chirurg. Apr 1989;60(4):235-9. [Medline].

  29. Farmer DG, McDiarmid SV, Yersiz H. Improved outcome after intestinal transplantation: an 8-year, single-center experience. Transplant Proc. Sep 2000;32(6):1233-4. [Medline].

  30. Filston HC, Colombani PM. Preliminary experience with intestinal transplantation in infants and children. Pediatrics. Apr 1996;97(4):583-4. [Medline].

  31. Finn L, Reyes J, Bueno J. Epstein-Barr virus infections in children after transplantation of the small intestine. Am J Surg Pathol. Mar 1998;22(3):299-309. [Medline].

  32. Freeman RB Jr, Steffick DE, Guidinger MK, et al. 2007 Annual Report of the U.S. Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients: Transplant Data 1997-2006. Rockville, MD: Department of Health and Human Services; 2007. [Full Text].

  33. Freeman RB Jr, Steffick DE, Guidinger MK, Farmer DG, Berg CL, Merion RM. Liver and intestine transplantation in the United States, 1997-2006. Am J Transplant. Apr 2008;8(4 Pt 2):958-76. [Medline].

  34. Frezza EE, Tzakis A, Fung JJ. Small bowel transplantation: current progress and clinical application. Hepatogastroenterology. Mar-Apr 1996;43(8):363-76. [Medline].

  35. Fryer JP. Intestinal transplantation: current status. Gastroenterol Clin North Am. Mar 2007;36(1):145-59, vii. [Medline].

  36. Fryer JP. The current status of intestinal transplantation. Curr Opin Organ Transplant. Jun 2008;13(3):266-72. [Medline].

  37. Giraldo M, Martin D, Colangelo J. Intestinal transplantation for patients with short gut syndrome and hypercoagulable states. Transplant Proc. Sep 2000;32(6):1223-4. [Medline].

  38. Gondolesi G, Blondeau B, Maurette R, et al. Pretransplant immunomodulation of highly sensitized small bowel transplant candidates with intravenous immune globulin. Transplantation. Jun 27 2006;81(12):1743-6. [Medline].

  39. Goulet O, Revillon Y, Canioni D, et al. Two and one-half-year follow-up after isolated cadaveric small bowel transplantation in an infant. Transplant Proc. Jun 1992;24(3):1224-5. [Medline].

  40. Grant D. Intestinal transplantation: 1997 report of the international registry. Intestinal Transplant Registry. Transplantation. Apr 15 1999;67(7):1061-4. [Medline].

  41. Grant D, Wall W, Mimeault R, et al. Successful small-bowel/liver transplantation. Lancet. Jan 27 1990;335(8683):181-4. [Medline].

  42. Grebe SC, Streilein JW. Graft-versus-Host reactions: a review. Adv Immunol. 1976;22:119-221. [Medline].

  43. Gruessner RW, Sharp HL. Living-related intestinal transplantation: first report of a standardized surgical technique. Transplantation. Dec 15 1997;64(11):1605-7. [Medline].

  44. Gura KM, Duggan CP, Collier SB, et al. Reversal of parenteral nutrition-associated liver disease in two infants with short bowel syndrome using parenteral fish oil: implications for future management. Pediatrics. Jul 2006;118(1):e197-201. [Medline].

  45. Hakim NS, Papalois VE. Small bowel transplantation. Int Surg. Oct-Dec 1999;84(4):313-7. [Medline].

  46. Herlenius G, Fagerlind M, Krantz M, et al. Chronic kidney disease--a common and serious complication after intestinal transplantation. Transplantation. Jul 15 2008;86(1):108-13. [Medline].

  47. Howard L, Ament M, Fleming CR, Shike M, Steiger E. Current use and clinical outcome of home parenteral and enteral nutrition therapies in the United States. Gastroenterology. Aug 1995;109(2):355-65. [Medline].

  48. Jeejeebhoy KN. Treatment of intestinal failure: transplantation or home parenteral nutrition?. Gastroenterology. Jul 2008;135(1):303-5. [Medline].

  49. Jugie M, Canioni D, Le Bihan C, et al. Study of the impact of liver transplantation on the outcome of intestinal grafts in children. Transplantation. Apr 15 2006;81(7):992-7. [Medline].

  50. Kahan BD. Cyclosporine. N Engl J Med. Dec 21 1989;321(25):1725-38. [Medline].

  51. Kato T, Berho M, Weppler D. Is severe rejection an indication for retransplantation?. Transplant Proc. Sep 2000;32(6):1201. [Medline].

  52. Kato T, Gaynor JJ, Nishida S, et al. Zoom endoscopic monitoring of small bowel allograft rejection. Surg Endosc. May 2006;20(5):773-82. [Medline].

  53. Kato T, Selvaggi G, Gaynor JJ, et al. Inclusion of donor colon and ileocecal valve in intestinal transplantation. Transplantation. Jul 27 2008;86(2):293-7. [Medline].

  54. Kato T, Tzakis AG, Selvaggi G, Gaynor JJ, David AI, Bussotti A, et al. Intestinal and multivisceral transplantation in children. Ann Surg. Jun 2006;243(6):756-64; discussion 764-6. [Medline]. [Full Text].

  55. Kato T, Tzakis AG, Selvaggi G, Gaynor JJ, Takahashi H, Mathew J, et al. Transplantation of the spleen: effect of splenic allograft in human multivisceral transplantation. Ann Surg. Sep 2007;246(3):436-44; discussion 445-6. [Medline]. [Full Text].

  56. Kim J, Fryer J, Craig RM. Absorptive function following small intestinal transplantation. Dig Dis Sci. Sep 1998;43(9):1925-30. [Medline].

  57. Kocoshis SA. Small bowel transplantation in infants and children. Gastroenterol Clin North Am. Dec 1994;23(4):727-42. [Medline].

  58. Kowalski RJ, Post DR, Mannon RB, et al. Assessing relative risks of infection and rejection: a meta-analysis using an immune function assay. Transplantation. Sep 15 2006;82(5):663-8. [Medline].

  59. Kusne S, Furukawa H, Abu-Elmagd K, et al. Infectious complications after small bowel transplantation in adults: an update. Transplant Proc. Oct 1996;28(5):2761-2. [Medline].

  60. Kusne S, Mañez R, Frye BL, St George K, Abu-Elmagd K, Tabasco-Menguillon J, et al. Use of DNA amplification for diagnosis of cytomegalovirus enteritis after intestinal transplantation. Gastroenterology. Apr 1997;112(4):1121-8. [Medline].

  61. Langnas AN, Shaw BW Jr, Antonson DL. Preliminary experience with intestinal transplantation in infants and children. Pediatrics. Apr 1996;97(4):443-8. [Medline].

  62. Langrehr JM, Banner B, Lee KK. Clinical course, morphology, and treatment of chronically rejecting small bowel allografts. Transplantation. Feb 1993;55(2):242-50. [Medline].

  63. Lauro A, Zanfi C, Ercolani G, et al. Italian experience in adult clinical intestinal and multivisceral transplantation: 6 years later. Transplant Proc. Jul-Aug 2007;39(6):1987-91. [Medline].

  64. Lee C. Pharmacokinetics of tacrolimus (FK506) prior to kidney transplantation. Clin Pharmacol Ther. 1993;62:2.

  65. Lillehei RC, Idezuki Y, Feemster JA. Transplantation of stomach, intestine, and pancreas: experimental and clinical observations. Surgery. Oct 1967;62(4):721-41. [Medline].

  66. Lopushinsky SR, Fowler RA, Kulkarni GS, Fecteau AH, Grant DR, Wales PW. The optimal timing of intestinal transplantation for children with intestinal failure: a Markov analysis. Ann Surg. Dec 2007;246(6):1092-9. [Medline].

  67. Madariaga JR, Reyes J, Mazariegos G. The long-term efficacy of multivisceral transplantation. Transplant Proc. Sep 2000;32(6):1219-20. [Medline].

  68. Margreiter R. The history of intestinal transplantation. Transplant Rev. 1977;11:9.

  69. Matsumoto CS, Kaufman SS, Girlanda R, et al. Utilization of donors who have suffered cardiopulmonary arrest and resuscitation in intestinal transplantation. Transplantation. Oct 15 2008;86(7):941-6. [Medline].

  70. Mazariegos GV, Kocoshis S. Patient selection for intestinal transplantation. Curr Opin Organ Transplant. 1998;3:293-97.

  71. Mazariegos GV, Reyes J. What's new in pediatric organ transplantation. Pediatr Rev. Nov 1999;20(11):363-75. [Medline].

  72. Mazariegos GV, Soltys KA, Bond GJ, Squires RH, Sindhi R. Isolated liver transplantation in infants with short gut syndrome: is less better?. Liver Transpl. Jul 2006;12(7):1040-1. [Medline].

  73. Messing B, Crenn P, Beau P, Boutron-Ruault MC, Rambaud JC, Matuchansky C. Long-term survival and parenteral nutrition dependence in adult patients with the short bowel syndrome. Gastroenterology. Nov 1999;117(5):1043-50. [Medline].

  74. Mian SI, Dutta S, Le B, Esquivel CO, Davis K, Castillo RO. Factors affecting survival to intestinal transplantation in the very young pediatric patient. Transplantation. May 15 2008;85(9):1287-9. [Medline].

  75. Modi BP, Javid PJ, Jaksic T, et al. First report of the international serial transverse enteroplasty data registry: indications, efficacy, and complications. J Am Coll Surg. Mar 2007;204(3):365-71. [Medline].

  76. Nalesnik M, Jaffe R, Reyes J. Posttransplant lymphoproliferative disorders in small bowel allograft recipients. Transplant Proc. Sep 2000;32(6):1213. [Medline].

  77. O'Keefe SJ, Buchman AL, Fishbein TM, Jeejeebhoy KN, Jeppesen PB, Shaffer J. Short bowel syndrome and intestinal failure: consensus definitions and overview. Clin Gastroenterol Hepatol. Jan 2006;4(1):6-10. [Medline].

  78. Peleg AY, Husain S, Kwak EJ, et al. Opportunistic infections in 547 organ transplant recipients receiving alemtuzumab, a humanized monoclonal CD-52 antibody. Clin Infect Dis. Jan 15 2007;44(2):204-12. [Medline].

  79. Pironi L, Forbes A, Joly F, et al. Survival of patients identified as candidates for intestinal transplantation: a 3-year prospective follow-up. Gastroenterology. Jul 2008;135(1):61-71. [Medline].

  80. Quintini C, Kato T, Gaynor JJ, et al. Analysis of risk factors for the development of posttransplant lymphoprolipherative disorder among 119 children who received primary intestinal transplants at a single center. Transplant Proc. 2006;38:1755-1758. [Medline].

  81. Reyes J. Liver and intestine transplantation. Immunol Allergy Clin North Am. 1996;16(2):293-312.

  82. Reyes J, Bueno J, Kocoshis S. Current status of intestinal transplantation in children. J Pediatr Surg. Feb 1998;33(2):243-54. [Medline].

  83. Reyes J, Green M, Bueno J, et al. Epstein Barr virus associated posttransplant lymphoproliferative disease after intestinal transplantation. Transplant Proc. Oct 1996;28(5):2768-9. [Medline].

  84. Roberts CA, Radio SJ, Markin RS. Histopathologic evaluation of primary intestinal transplant recipients at autopsy: a single-center experience. Transplant Proc. Sep 2000;32(6):1202-3. [Medline].

  85. Rowe DT, Qu L, Reyes J, Jabbour N, Yunis E, Putnam P, et al. Use of quantitative competitive PCR to measure Epstein-Barr virus genome load in the peripheral blood of pediatric transplant patients with lymphoproliferative disorders. J Clin Microbiol. Jun 1997;35(6):1612-5. [Medline]. [Full Text].

  86. Ruiz P, Bagni A, Brown R, et al. Histological criteria for the identification of acute cellular rejection in human small bowel allografts: results of the pathology workshop at the VIII International Small Bowel Transplant Symposium. Transplant Proc. Mar 2004;36(2):335-7. [Medline].

  87. Scientific Registry of Transplant Recipients. Available at www.ustransplant.org. Accessed November 2008.

  88. Selvaggi G, Gaynor JJ, Moon J, et al. Analysis of acute cellular rejection episodes in recipients of primary intestinal transplantation: a single center, 11-year experience. Am J Transplant. May 2007;7(5):1249-57. [Medline].

  89. Sudan D, Vargas L, Sun Y, Bok L, Dijkstra G, Langnas A. Calprotectin: a novel noninvasive marker for intestinal allograft monitoring. Ann Surg. Aug 2007;246(2):311-5. [Medline]. [Full Text].

  90. Sudan DL, Iverson A, Weseman RA, et al. Assessment of function, growth and development, and long-term quality of life after small bowel transplantation. Transplant Proc. Sep 2000;32(6):1211-2. [Medline].

  91. Sudan DL, Kaufman S, Horslen S. Incidence, timing, and histologic grade of acute rejection in small bowel transplant recipients. Transplant Proc. Sep 2000;32(6):1199. [Medline].

  92. Takahashi H, Kato T, Selvaggi G, et al. Subclinical rejection in the initial postoperative period in small intestinal transplantation: a negative influence on graft survival. Transplantation. Sep 27 2007;84(6):689-96. [Medline].

  93. Thevenin DM, Baker A, Kato T, et al. Neurodevelopmental outcomes for children transplanted under the age of 3 years. Transplant Proc. 2006;38:1692-1693.

  94. Thevenin DM, Baker A, Kato T, et al. Neurodevelopmental outcomes of infant multivisceral transplant recipients: A longitudinal study. Transplant Proc. 2006;38:1694-1695.

  95. Thompson JS. Intestinal transplantation. Experience in the United States. Eur J Pediatr Surg. Aug 1999;9(4):271-3. [Medline].

  96. Todo S, Tzakis A, Abu-Elmagd K. Current status of intestinal transplantation. Adv Surg. 1994;27:295-316. [Medline].

  97. Tzakis AG, Kato T, Levi DM, Defaria W, Selvaggi G, Weppler D, et al. 100 multivisceral transplants at a single center. Ann Surg. Oct 2005;242(4):480-90; discussion 491-3. [Medline]. [Full Text].

  98. United Network for Organ Sharing. Available at www.unos.org. Accessed November 2008.

  99. Watson MJ, Venick RS, Kaldas F, et al. Renal function impacts outcomes after intestinal transplantation. Transplantation. Jul 15 2008;86(1):117-22. [Medline].

  100. Zanfi C, Cescon M, Lauro A, et al. Incidence and management of abdominal closure-related complications in adult intestinal transplantation. Transplantation. Jun 15 2008;85(11):1607-9. [Medline].

  101. Zanfi C, Lauro A, Cescon M, et al. Recovery From Liver Dysfunction After Adult Isolated Intestinal Transplantation Without Liver Grafting. Transplantation (Supplement). July 2008;86:210.

 
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Number of candidates on the intestine waiting list active at year-end (1997-2006).
Number of candidates on the intestine waiting list by age at year-end (1997-2006).
Median time to transplant for new intestine waiting list registration (1998-2006).
Isolated small bowel graft.
Liver-small bowel graft, including the pancreas.
Multivisceral graft, including stomach-liver-pancreas-small bowel and right colon.
Isolated intestinal transplant. A gastrostomy tube, jejunostomy tube, and loop ileostomy are in place.
 
 
 
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