The Coming of Age of Isolated Small Bowel Transplantation?
Abstracts
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Candidates for small bowel transplantation (SBTx) often have concomitant TPN-related liver failure and require composite intestinal/liver grafts, which have been associated with technical complexities, sustained high levels of immunosuppression (IS) and high mortality. Here we review our results with isolated SBTx in patients with intestinal failure who were TPN-dependent but had no liver failure. Methods: Between 1998-2001, 17 TPN-dependent patients (6 pediatric, 3M, 3F; mean age 3.4?2.9 yr); 11 adult, 2M, 9F; mean age 36.3?9.3 yr) with little or no liver dysfunction who were not candidates for (or had failed) intestinal rehabilitation received 19 isolated small bowel grafts. All were T cell crossmatch negative. All received tacrolimus-based IS; starting in June 2000, all patients also received sirolimus and basiliximab. Results: Etiologies of intestinal failure among children was malrotation, intestinal atresia, pseudo-obstruction (n=2), and microvillous inclusion disease (n=2). Etiologies of intestinal failure among adults was trauma, visceral myopathy, radiation enteritis, volvulus, mesenteric thrombosis (n=2), desmoid tumor (n=2), and Crohn?s disease (n=3). Twelve patients (70.6%) were short gut with <50cm total jejunum/ileum. Twelve grafts were drained systemically; 7 were drained into the portal system. All patients survived transplantation. Four lost their grafts (3 to rejection, 1 to thrombosis); 2 were successfully retransplanted. Two patients died, 1 of intracranial hemorrhage (POD 46) and 1 of sepsis (POD 60); both were free of TPN at death. All surviving patients are TPN-free except for the 2 who lost their grafts and have not undergone retransplant. The 1 who died of sepsis and the 4 who lost their grafts did not receive sirolimus. Actuarial 2-yr graft survival for pediatric and adult patients was 50% and 78%, respectively. Actuarial 2-yr patient survival for pediatric and adult patients was 67% and 90%, respectively. Overall 2-yr actuarial patient and graft survival was 70% and 83%, respectively. Conclusions: Isolated SBTx with tacrolimus and sirolimus-based IS can be performed in patients without TPN-related hepatic dysfunction with good patient and graft survival. High patient and graft survival rates in adults now allow us to offer isolated SBTx to a broader population of patients with intestinal failure. We approach an era in which this therapy may be safely offered to patients with irreversible intestinal failure prior to the development of life threatening complications of TPN. |
