Three years clinical experience with intestinal transplantation

Abstract

Background: After the successful evolution of hepatic transplantation during the last decade, small bowel and multivisceral transplantation remains the sole elusive achievement for the next era of transplant surgeons. Until recently, and for the last thirty years, the results of the sporadic attempts of intestinal transplantation worldwide were discouraging because of unsatisfactory graft and patient survival. The experimental and clinical demonstration of the superior therapeutic efficacy of FK 506, a new immunosuppressive drug, ushered in the current era of small bowel and multivisceral transplantation with initial promising results.

Study design: Forty-three consecutive patients with short bowel syndrome, intestinal insufficiency, or malignant tumors with or without associated liver disease, were given intestinal (n = 15), hepatic and intestinal (n = 21), or multivisceral allografts that contained four or more organs (n = 7). Treatment was with FK 506 based immunosuppression. The ascending and right transverse colon were included with the small intestine in 13 of the 43 grafts, almost evenly distributed between the three groups.

Results: After six to 39 months, 30 of the 43 patients are alive, 29 bearing grafts. The most rapid convalescence and resumption of diet, as well as the highest three month patient survival (100 percent) and graft survival (88 percent) were with the isolated intestinal procedure. However, this advantage was slowly eroded during the first two postoperative years, in part because the isolated intestine was more prone to rejection. By the end of this time, the best survival rate (86 percent) was with the multivisceral procedure. With all three operations, most of the patients were able to resume diet and discontinue parenteral alimentation, and in the best instances, the quality of life approached normal. However, the surveillance and intensity of care required for these patients for the first year, and in most instances thereafter, was very high, being far more than required for patients having transplants of the liver, kidney or heart.

Conclusions: Although intestinal transplantation has gone through the feasibility phase, strategies will be required to increase its practicality. One possibility is to combine intestinal transplantation with contemporaneous autologous bone marrow transplantation.

Fig. 1

Isolated intestinal transplantation including one-half of the colon (main figure) or the small intestine only (left insert) is shown. Graft venous outflow is drained end-to-side (main figure) or end-to-end (right insert) into the host portal system. IVC, Inferior vena cava.

Fig. 2

Hepatic and intestinal transplantation including part of the colon (main figure) or with small intestine only (left insert) are shown. The host portal vein is drained into the graft portal vein when possible, but in one-third of the instances, this blood was diverted into the vena cava (right insert). CA, Celiac artery; PV, portal vein; IVC, inferior vena cava, and SMA, superior mesenteric artery.

Fig. 3

Depicted is a full multivisceral operation including the ascending and right transverse colon. Note that pyloroplasty or pyloromyotomy was performed and that bile flow was temporarily decompressed in all instances.

Fig. 4

FK 506 plasma trough levels and FK 506 and prednisone doses in the three patient cohorts. Values are mean plus or minus standard error of the mean.

Fig. 5

a, Patient survival rate, all 43 recipients, and b, patient survival rate according to procedure.

Fig. 6

a, Graft survival rate, all 45 attempts including two retransplantations, and b, graft survival rate according to procedure.

Fig. 7

a, Weight and height performance of children with intestinal graft in place, and b, weight performance of adult recipients.