Abstracts
2000 Digestive Disease Week

# 2326 Successful Intestinal Transplantation: Surgical and Immunological Considerations.
Menahem Ben-Haim, Thomas M. Fishbein, Thomas Schiano, Sukru Emre, Marcelo Facciuto, Patricia A. Sheiner, Myron E. Schwartz, Charles M. Miller, New York, NY

Introduction: In a recently established intestinal failure and transplantation program, 13 patients received isolated intestinal grafts or multiorgan grafts (including small bowel) for complications of parenteral nutrition (TPN) or for nonreconstructible gastrointestinal tracts. Methods: Four children (age <1 yr, n=3; age 8 yr, n=1) and 9 adults (mean age, 39±19 yr; range, 19-57) underwent transplantation for cholestatic liver failure (n=4), recurrent line sepsis (n=6), or tumor-related complications (n=3). Isolated intestinal grafts were used in 9 patients, liver/bowel grafts in 4, and a multiorgan graft without the liver in 1. Arterial inflow was restored from the infrarenal (n=13) or supraceliac (n=1) aorta, with (n=4) or without (n=10) arterial grafts. Inflow was to the donor SMA alone (n=9), donor SMA and celiac arteries (via Y graft, n=2) or donor aorta (n=3). Isolated intestinal grafts had portal drainage (n=2) or systemic drainage (n=7). In the combined liver/bowel grafts, a porto-caval shunt was created with the native portal vein (n=4) to allow drainge of the native abdominal viscera. Proximal enteric reconstruction was to the duodenum (n=8), proximal jejunum (n=5) or esophagus in the multiorgan graft. Simple end ileostomy (n=9) or anastomosis to the left colon together with a Bishop-Koop ileostomy (n=5) were performed distally. Immunosuppression included tacrolimus, steroids, and mycophenolate mofetil. Pretransplant crossmatches were negative. Frequent mucosal biopsies were utilized to detect rejection within the first 6 weeks. Results: Ten patients (77%) are alive; 9 are free of parenteral nutrition (TPN) (mean follow-up, 7 mos, range, 2-16). Three patients (nos. 1, 4 and 6) died of sepsis (22, 45 and 148 days posttransplant). Graft survival is 64%; TPN independence is 69%. One graft was lost to ischemia; the patient was successfully retransplanted. One graft was lost to severe rejection; this patient awaits retransplantation. Ten grafts developed =1 rejection episode. No patient suffered more than 2 rejection episodes. Early complications (<30 days) included reoperation for bleeding, obstruction or abdominal sepsis in 9 patients. All patients surviving with grafts enjoy full enteral nutrition with minimal antidiarrheals. Conclusions: Intestinal transplantation can be successful in a new program. Discontinuation of TPN can be achieved in most patients. Severe rejection with graft loss is not prevented by lymphocytotoxic crossmatching, but crossmatching may limit recurrent rejection.