Cadaveric small bowel and small bowel-liver transplantation in humans

Abstract

Five patients had complete cadaveric small bowel transplants under FK506 immunosuppression, one as an isolated graft and the other 4 in continuity with a liver. Three were children and two were adults. The five patients are living 2-13 months posttransplantation with complete alimentation by the intestine. The typical postoperative course was stormy, with sluggish resumption of gastrointestinal function. The patient with small intestinal transplantation alone had the most difficult course of the five, including two severe rejections, bacterial and fungal translocation with bacteremia, renal failure with the rejections, and permanent consignment to renal dialysis. The first four patients (studies on the fifth were incomplete) had replacement of the lymphoreticular cells in the graft lamina propria by their own lymphoreticular cells. Although the surgical and after-care of these patients was difficult, the eventual uniform success suggests that intestinal transplantation has moved toward becoming a practical clinical service.

Figure 1

Liver plus small bowel transplantation. Native liver is replaced by the piggyback technique with the recipient’s portal blood drainage into the graft portal vein or into the inferior vena cava (inset—right). Two ends of the intestinal graft are exteriorized by chimney enterostomy at the left upper and right lower quadrant of the abdomen (inset—left) .

Figure 2

Clinical course of patient 1 who received an isolated small bowel graft. He had a stormy course in the immediate postoperative period, with severe rejection, bacteremia and renal failure requiring dialysis. (TPN, total parenteral nutrition; arrows = ACR (acute cellular rejection) and SM (solumedroll, boluses; SB, small bowel.

Figure 3

Clinical course of patient 2 who received a liver–plus–small bowel graft. The first episode of intestinal graft rejection (POD 18) was treated by augmentation of the FK dose. Note the rapid decline of the total bilirubin.

Figure 4

All but one patient gained body weight, from 5 to 21%, at 2–10 months postoperatively. They are supported entirely by their intestinal transplants.

Figure 5

D-xylose absorption tests in 4 small bowel recipients. Absorption in patient 1 (left) was normal until 4 months postoperatively, but was suppressed shortly after when he had drug-noncompliant rejection at 166 days. D-xylose absorption in patients 2 and 3 was normal at 8–9 months postoperatively, and was satisfactory in patient 4. Patient 5 has not been tested yet.