Intestinal and Multivisceral Transplantation Workup

  • Author: Richard K Gilroy, MBBS, FRACP; Chief Editor: Ron Shapiro, MD   more...
 
Updated: May 2, 2012
 

Laboratory Studies

  • Complete blood cell count
  • Prothrombin time and activated partial thromboplastin time
  • Electrolytes, blood urea nitrogen, and creatinine
  • Total and direct bilirubin
  • Aspartate transaminase, alanine aminotransferase, alkaline phosphatase, and gamma glutamyl transferase
  • Serum albumin
  • Phosphorous and magnesium
  • Cholesterol and triglycerides
  • Zinc and selenium
  • Free and total carnitine
  • Vitamins A, D, and E
  • Cytomegalovirus (CMV), Epstein-Barr virus (EBV), hepatitis B virus, hepatitis C virus, and human immunodeficiency virus
  • Alpha-fetoprotein
  • Cytotoxic antibody screen
Next

Imaging Studies

  • Chest radiography
  • Abdominal ultrasonography
  • Doppler study of upper extremity veins
  • Bone age study
  • Echocardiography
Previous
Next

Other Tests

  • Electrocardiography
  • Motility studies (as indicated)
  • Liver biopsy (as indicated)
  • Upper gastrointestinal endoscopy
Previous
Next

Histologic Findings

TPN cholestasis without significant fibrosis (This is a reversible pathology at this point.)

PN cholestasis. (This is a reversible pathology atPN cholestasis. (This is a reversible pathology at this point as an absence of fibrosis.)
Previous
Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

Richard K Gilroy, MBBS, FRACP  Associate Professor, Medical Director of Liver Transplantation and Hepatology, Department of Internal Medicine, Kansas University Medical Center

Disclosure: genetech, gilead, NPS pharmaceuticals Salary Speaking and teaching

Coauthor(s)

Jean Frederick Botha, MBBCh, FCS(SA)  Assistant Professor of Surgery, Transplant Surgeon, Department of Surgery, University of Nebraska Medical Center

Disclosure: Nothing to disclose.

Debra L Sudan, MD  Professor of Surgery, Chief, Abdominal Transplant Surgery, Vice Chair of Clinical Operations, Department of Surgery, Duke University School of Medicine

Debra L Sudan, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society of Transplant Surgeons, American Society of Transplantation, American Surgical Association, Association for Academic Surgery, Association of Women Surgeons, Association of Women Surgeons, International Liver Transplantation Society, Nebraska Medical Association, Society for Surgery of the Alimentary Tract, and Society of University Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Debra L Sudan, MD  Professor of Surgery, Chief, Abdominal Transplant Surgery, Vice Chair of Clinical Operations, Department of Surgery, Duke University School of Medicine

Debra L Sudan, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society of Transplant Surgeons, American Society of Transplantation, American Surgical Association, Association for Academic Surgery, Association of Women Surgeons, Association of Women Surgeons, International Liver Transplantation Society, Nebraska Medical Association, Society for Surgery of the Alimentary Tract, and Society of University Surgeons

Disclosure: Nothing to disclose.

Chief Editor

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

Additional Contributors

Dr. Wendy Grant, Assistant Professor of Surgery, Section of Transplantation, University of Nebraska Medical Center, for providing the multimedia images in this article.

The Intestinal Transplantation Registry (ITR) for providing the charts in this article.

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Sandeep Mukherjee, MD, to the development and writing of this article.

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Anatomy of the donor operation, with procurement of the liver, small bowel, pancreas, and spleen en bloc (AO, thoracic aorta; HA, hepatic artery; PV, portal vein; CBD, common bile duct; D1, first part of the duodenum; TI, terminal ileum).
Small bowel recipient operation (AOI, interposition graft of aorta; AOII, Carrel patch bearing celiac trunk and superior mesenteric artery; AOIII, aortic end oversewn below superior mesenteric artery take-off; SV, native splenic vein; P, pancreas, with duct and parenchymal edge oversewn; PB, proximal bowel anastomosis; DB, distal ileocolonic anastomosis; LS, diverting loop ileostomy).
Back table operation with mesenteric vessels held within the forceps and the donor intestine within preservation solution.
Intestinal graft within the abdominal cavity of the recipient at the time of revascularization.
Revascularized bowel prior to closure. In the lower right corner the anastomosis between the donor small bowel and recipient remnant colon can be seen.
Picture of the liver and small bowel allograft. The liver is to the left of the picture, and the spleen can be seen lying within the loops of the small bowel (spleen is removed later).
Removal of the native liver. Left behind is the cavity into which the liver and small bowel allograft will be placed.
Postrevascularization image of the liver and small bowel allograft.
The allograft, prior to closure, positioned within the recipient's abdomen. The wedge-shaped excision (biopsy site) seen on the donor organ was performed at organ procurement. These biopsies are selectively performed to review the suitability of organs in instances where issues of suitability are raised.
Survival figures 2007. Image courtesy of the Intestinal Transplantation Registry (ITR).
PN cholestasis. (This is a reversible pathology at this point as an absence of fibrosis.)
Intestinal transplants by year. Image courtesy of the Intestinal Transplantation Registry (ITR).
Intestinal Transplantatio. A Pretransplant diagnosis-children, B pretransplant diagnosis-adults
Survival by era
Survival (2004–2009) by graft type
Survival (2004–2009) by pretransplant status
Graft survival by the liver, included or not (1985–2009)
Table 1. Proposed Immunosuppression Targets
MedicationDays 2-29Days 30-89Days 90-179Days 180-365After 1 year
Tacrolimus (monotherapy levels)15-20 ng/mL12-15 ng/mL10-12 ng/mL7-10 ng/mLTaper to around 5 ng/mL
Tacrolimus (in combination levels)10-15 ng/mL8-12 ng/mL8-10 ng/mL5-8 ng/mL2.5-5 ng/mL
Prednisone (dose)20 mg15 mg10 mg7.5 mg5 mg
Rapamycin (to be used only in combination with tacrolimus)6-10 ng/mL5-8 ng/mL5-8 ng/mL5-8 ng/mL5-8 ng/mL
Mycophenolic acid (suggested dose as listed and to be used only in combination with tacrolimus; dose listed is adult dose; intolerance may be managed by lowering dose) 1000 mg bid1000 mg bidCease unless renal indication exists......
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