eMedicine Specialties > Pediatrics: Surgery > Transplantation

Intestinal and Multivisceral Transplantation: Follow-up

Author: Seigo Nishida, MD, PhD, Associate Director of Adult Intestinal Transplant Program, Associate Professor of Clinical Surgery, Division of Liver/GI Transplantation, Department of Surgery, University of Miami School of Medicine
Coauthor(s): Andreas G Tzakis, MD, PhD, Professor, Department of Surgery, Miller School of Medicine, University of Miami; David M Levi, MD, Associate Professor of Clinical Surgery, Department of Surgery, Division of Liver and Gastrointestinal Transplantation, Division of General Surgery, Jackson Memorial Hospital, Miller School of Medicine, University of Miami; Tomoaki Kato, MD, Associate Professor of Clinical Surgery, Department of Surgery, Division of Liver and Gastrointestinal Transplantation, Miller School of Medicine, University of Miami; Jose R Nery, MD, Associate Professor, Department of Surgery, Division of Liver and Gastrointestinal Transplantation, Miller School of Medicine, University of Miami; Juan Madariaga, MD, Professor, Department of Surgery, Miller School of Medicine, University of Miami; John F Thompson, MD, Associate Professor, Department of Pediatrics, Miller School of Medicine, University of Miami; Phillip Ruiz, Jr, MD, PhD, Professor of Pathology, Department of Pathology and Surgery, Miller School of Medicine, University of Miami; G Patricia Cantwell, MD, Associate Clinical Professor, Department of Pediatrics, University of Miami; Director of Pediatric Critical Care Medicine, Miller School of Medicine, Jackson Children's Hospital
Contributor Information and Disclosures

Updated: Jan 24, 2008

Outcome and Prognosis

Patient and graft survival

The International Registry for Intestinal Transplantation reports that graft and patient survival rates have improved, with a 69% 1-year patient survival rate and a 55% graft survival rate since 1995.22 At the University of Miami, the 1-year patient survival rate is 75%, and the graft survival rate is 68% since 1994. Since 1998, the 1-year patient survival rate is 84%, and the graft survival rate is 72% (see Media file 9). In 1998, the authors introduced the ZVE and biopsy protocol and daclizumab induction therapy for all intestinal and multivisceral recipients. The authors attribute the improvement in patient and graft survival rates since 1998 to these 2 modifications in the program.

The authors are certain that earlier referral of the patients for intestinal transplantation yields improved survival results. The authors' results do show that isolated transplantation is preferable to combined liver-intestinal or multivisceral transplantation from a survival standpoint. Posttransplant prognosis is also improved when transplantation is performed prior to the onset of liver failure and prior to the exhaustion of all routes of vascular access.

Causes of death included the following:

  • Sepsis after rejection
  • Respiratory failure
  • Sepsis
  • Multiple organ failure
  • Arterial graft infection
  • Aspergillosis
  • Posttransplantation lymphoproliferative disorder
  • Intracranial bleeding
  • Fungemia
  • Chronic rejection
  • Graft versus host disease
  • Necrotizing enterocolitis
  • Pancreatitis
  • Pulmonary embolism
  • Viral encephalitis

Future and Controversies

Current state of intestinal transplantation

Most recipients of intestinal transplants are free from TPN and enjoy an excellent quality of life. Intestinal transplantation has matured into a life-saving and cost-effective therapy for patients with intestinal failure.27 Rejection and infection are still the 2 most perplexing problems surrounding intestinal and multivisceral transplantation. Earlier patient referral, the development of new immunosuppressive agents, and the discovery of a serum marker for graft rejection are the keys to continued improvements in graft and patient survival rates.

Evolution and future directions

Since 1998, the authors have been changing many things, such as surgical technique, CMV prophylaxis, rejection monitoring with ZVE, new immunosuppression, and prevention of overimmunosuppression. These changes have contributed to the recent improvement in the survival rate.

Systemic drainage to the inferior vena cava has been applied, and results are satisfactory. Metabolic effect and survival rates are the same as for portal drainage. CMV-positive donors are used safely with intense CMV prophylaxis by CytoGam. Rejection monitoring with ZVE prevents the delay of the diagnosis of the rejection and overimmunosuppression. Zenapax, rapamycin, and Campath are ongoing new immunosuppression therapies. These evolutions have improved the results of intestinal transplantation since 1998. New findings from basic research may contribute to the improvement of small bowel transplantation.

Enterocytes have been studied at the University of Miami hospital. The study demonstrated the presence of host-derived (male) enterocytes in the intestinal allografts (female). The presence of male crypt cells and male enterocytes in the intestinal grafts suggested that they probably originated from circulating stem cells and that the differentiation process might have progressed from crypt cells to mature enterocytes. Generating enterocytes from a patient's own stem cells may be possible; this might assist in developing novel strategies to increase intestinal absorptive surface and repair and to engineer neointestines for patients with short bowel syndrome.

The authors' clinical study also demonstrated some promising preliminary data about serum citrulline as a marker for early acute cellular rejection after intestinal transplantation. These findings might help the rejection monitoring.

Newer immunosuppressive medications with more specific actions, further advancement of rejection monitoring, and infection control are urgently required. Continuing efforts will contribute to future success.

 
Acknowledgments

The authors gratefully acknowledge Brian Dunkin, MD, for his support involving endoscopy and patient care. The authors also acknowledge Joseph Tector, MD, for his support of this manuscript. The authors would also like to thank Debbie Weppler, RN, for her contribution of intestinal patient management and data collection.



More on Intestinal and Multivisceral Transplantation

Overview: Intestinal and Multivisceral Transplantation
Workup: Intestinal and Multivisceral Transplantation
Treatment: Intestinal and Multivisceral Transplantation
Follow-up: Intestinal and Multivisceral Transplantation
Multimedia: Intestinal and Multivisceral Transplantation
References
[ CLOSE WINDOW ]

References

  1. Carrel A. La technique operatoire des anastomoses vasculaires et la transplantation des visceres. Lyon MEO. 1902;98:859.

  2. 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 small bowel with successful replacement and survival. Ann Surg. 1959;150:543-60.

  3. Starzl TE, Kaupp HA Jr. Mass homotransplantation of abdominal organs in dogs. Surg Forum. 1960;11:28-30.

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

  5. Okumura M, Mester M. The coming of age of small bowel transplantation: a historical perspective. Transplant Proc. Jun 1992;24(3):1241-2. [Medline].

  6. Grant D, Duff J, Zhong R, et al. Successful intestinal transplantation in pigs treated with cyclosporine. Transplantation. Feb 1988;45(2):279-84. [Medline].

  7. Starzl TE, Rowe MI, Todo S. Transplantation of multiple abdominal viscera. JAMA. Mar 10 1989;261(10):1449-57. [Medline].

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

  9. Todo S, Tzakis AG, Abu-Elmagd K, et al. Intestinal transplantation in composite visceral grafts or alone. Ann Surg. Sep 1992;216(3):223-33; discussion 233-4. [Medline].

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

  11. Tzakis A, Webb M, Nery J, et al. Experience with intestinal transplantation at the University of Miami. Transplant Proc. Oct 1996;28(5):2748-9. [Medline].

  12. Tzakis AG, Kato T, Nishida S, et al. Alemtuzumab (Campath-1H) combined with tacrolimus in intestinal and multivisceral transplantation. Transplantation. May 15 2003;75(9):1512-7. [Medline].

  13. Abu-Elmagd K, Reyes J, Todo S, et al. Clinical intestinal transplantation: new perspectives and immunologic considerations. J Am Coll Surg. May 1998;186(5):512-25; discussion 525-7. [Medline].

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

  15. Quigley EM. Small intestinal transplantation: reflections on an evolving approach to intestinal failure. Gastroenterology. Jun 1996;110(6):2009-12. [Medline].

  16. Abu-Elmagd K, Fung J, Bueno J, 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].

  17. Sabatini DM, Erdjument-Bromage H, Lui M, et al. RAFT1: a mammalian protein that binds to FKBP12 in a rapamycin-dependent fashion and is homologous to yeast TORs. Cell. Jul 15 1994;78(1):35-43. [Medline].

  18. Foster PF, Sankary HN, McChesney L, et al. Cytomegalovirus infection in the composite liver/intestinal/pancreas allograft. Transplant Proc. Oct 1996;28(5):2742-3. [Medline].

  19. Nishida S, Levi DM, Moon JI, et al. Intestinal transplantation with alemtuzumab (Campath-1H) induction for adult patients. Transplant Proc. Jul-Aug 2006;38(6):1747-9. [Medline].

  20. Kato T, O'Brien CB, Nishida S, et al. The first case report of the use of a zoom videoendoscope for the evaluation of small bowel graft mucosa in a human after intestinal transplantation. Gastrointest Endosc. Aug 1999;50(2):257-61. [Medline].

  21. Pappas PA, Tzakis AG, Saudubray JM. Trends in serum citrulline and acute rejection among recipients of small bowel transplants. Transplant Proc. Mar 2004;36(2):345-7. [Medline].

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

  23. Calne RY, Sells RA, Pena JR, et al. Induction of immunological tolerance by porcine liver allografts. Nature. Aug 2 1969;223(205):472-6. [Medline].

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

  25. Horslen SP, Kaufman SS, Sudan DL. Isolated liver transplantation in infants with total parenteral nutrition-associated end-stage liver disease. Transplant Proc. Sep 2000;32(6):1241. [Medline].

  26. Asfar S, Atkison P, Ghent C, et al. Small bowel transplantation. A life-saving option for selected patients with intestinal failure. Dig Dis Sci. May 1996;41(5):875-83. [Medline].

  27. Abu-Elmagd KM, Reyes J, Fung JJ, et al. Evolution of clinical intestinal transplantation: improved outcome and cost effectiveness. Transplant Proc. Feb-Mar 1999;31(1-2):582-4. [Medline].

  28. Casavilla A, Selby R, Abu-Elmagd K, et al. Logistics and technique for combined hepatic-intestinal retrieval. Ann Surg. Nov 1992;216(5):605-9. [Medline].

  29. Deltz E, Mengel W, Hamelmann H. Small bowel transplantation: report of a clinical case. Prog Pediatr Surg. 1990;25:90-6. [Medline].

  30. Garcia M, Weppler D, Mittal N. Campath-1H immunosuppressive therapy reduces incidence and intensity of acute rejection in intestinal and multivisceral transplantation. Transplant Proc. Mar 2004;36(2):323-4. [Medline].

  31. 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].

  32. Reyes J, Todo S, Bueno J, et al. Intestinal transplantation in children: five-year experience. Transplant Proc. Oct 1996;28(5):2755-6. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

intestinal transplantation, multivisceral transplantation, polysplanchnic transplantation, intestinal failure, short bowel syndrome, total parenteral nutrition, TPN, cytomegalovirus, CMV, polysplanchnic transplantation, volvulus, thrombosis, encephalopathy, tetany, calcium deficiency, magnesium deficiency, hyperalimentation, necrotizing enterocolitis, mesenteric thrombosis, gastroschisis, desmoid tumor, intestinal atresia, Hirschsprung disease, Crohn disease, pseudoobstruction, microvillus inclusion disease, central vein thrombosis, cholestatic TPN-induced liver failure, catheter-associated sepsis, catheter-associated vascular thrombosis

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Seigo Nishida, MD, PhD, Associate Director of Adult Intestinal Transplant Program, Associate Professor of Clinical Surgery, Division of Liver/GI Transplantation, Department of Surgery, University of Miami School of Medicine
Seigo Nishida, MD, PhD is a member of the following medical societies: American Society of Transplant Surgeons, Japan Surgical Society, Society for Surgery of the Alimentary Tract, and Transplantation Society
Disclosure: Nothing to disclose.

Coauthor(s)

Andreas G Tzakis, MD, PhD, Professor, Department of Surgery, Miller School of Medicine, University of Miami
Andreas G Tzakis, MD, PhD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Angiology, American College of Surgeons, American Medical Association, American Society of Transplant Surgeons, American Spinal Injury Association, International College of Surgeons, Pennsylvania Medical Society, and Society of University Surgeons
Disclosure: Nothing to disclose.

David M Levi, MD, Associate Professor of Clinical Surgery, Department of Surgery, Division of Liver and Gastrointestinal Transplantation, Division of General Surgery, Jackson Memorial Hospital, Miller School of Medicine, University of Miami
Disclosure: Nothing to disclose.

Tomoaki Kato, MD, Associate Professor of Clinical Surgery, Department of Surgery, Division of Liver and Gastrointestinal Transplantation, Miller School of Medicine, University of Miami
Tomoaki Kato, MD is a member of the following medical societies: American Gastroenterological Association, American Medical Association, and American Society of Transplant Surgeons
Disclosure: Nothing to disclose.

Jose R Nery, MD, Associate Professor, Department of Surgery, Division of Liver and Gastrointestinal Transplantation, Miller School of Medicine, University of Miami
Disclosure: Nothing to disclose.

Juan Madariaga, MD, Professor, Department of Surgery, Miller School of Medicine, University of Miami
Juan Madariaga, MD is a member of the following medical societies: American Medical Association, American Society of Transplant Surgeons, Medical Society of the State of New York, and Society of Surgical Oncology
Disclosure: Nothing to disclose.

John F Thompson, MD, Associate Professor, Department of Pediatrics, Miller School of Medicine, University of Miami
John F Thompson, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

Phillip Ruiz, Jr, MD, PhD, Professor of Pathology, Department of Pathology and Surgery, Miller School of Medicine, University of Miami
Phillip Ruiz, Jr, MD, PhD is a member of the following medical societies: American Association for the Advancement of Science, American Association of Immunologists, American Society of Clinical Pathologists, American Society of Nephrology, American Society of Transplant Surgeons, American Society of Transplantation, Clinical Immunology Society, Florida Medical Association, New York Academy of Sciences, Pan American Medical Association, Southern Medical Association, and United States and Canadian Academy of Pathology
Disclosure: Nothing to disclose.

G Patricia Cantwell, MD, Associate Clinical Professor, Department of Pediatrics, University of Miami; Director of Pediatric Critical Care Medicine, Miller School of Medicine, Jackson Children's Hospital
G Patricia Cantwell, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Casimir F Firlit, MD, PhD, Consulting Staff, Department of Urology, Cardinal Glennon Children's Hospital
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.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Brian F Gilchrist, MD, Chief, Division of Pediatric Surgery, Tufts-New England Medical Center; Associate Professor, Department of Surgery, Tufts University School of Medicine
Disclosure: Nothing to disclose.

CME Editor

Ron Shapiro, MD, Professor of Surgery, University of Pittsburgh; 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: Nothing to disclose.

Chief Editor

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.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.