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Summer 1996Volume 3, Number 1 |
Intestinal transplantation is still in its infancy. To promote progress and advance research, scientists and clinicians in this field need to meet and discuss their experiences in order for this technique to become a therapeutic option for patients who have irreversible intestinal failure. To achieve this goal, the International Symposium on Small Bowel Transplantation was first held in St. Bartholomew, England, in 1989, and subsequently in London and Ontario in 1991, and in Paris, France, in 1993. The Pittsburgh Transplantation Institute of the University of Pittsburgh hosted the fourth symposium in October of last year, and more than 350 scientists, physicians, and nurses gathered to discuss 229 papers submitted from 17 countries.
The Pittsburgh symposium consisted of two sections: basic science and clinical experience. Topics in basic science included immunology, immunosuppression, ischemia/preservation, motility, absorption, innervation, gastrointestinal hormones, and bacterial overgrowth/translocation all of which are essential for the understanding and management of intestinal failure and intestinal transplantation. Thirteen invited speakers gave their expert opinions on each of these subjects. In the clinical section, 14 intestinal transplantation centers presented their results, representing two thirds of the world's experience. They discussed indications, operative procedures, immunosuppression, monitoring and treatment of rejection, graft-versus-host disease, complications, and outcome after intestinal transplantation.
The current clinical status of intestinal transplantation was presented in a report from the International Intestinal Transplantation Registry. A total of 180 intestinal transplants were performed in 170 patients at 25 centers worldwide between 1985 and June, 1995. Cyclosporine was used to prevent rejection in 49 grafts, and tacrolimus was used in 129 grafts. Approximately 30 transplants were performed yearly between 1992 and 1994. About 30 cases were done within the first six months of 1995, reflecting increasing interest in this procedure. Short-term results following intestinal transplantation in patients receiving tacrolimus-based therapy approached the results achieved with lung transplantation. One- and three-year graft survival rates after transplantation of isolated grafts (48), combined liver/intestine grafts (64), and abdominal multivisceral grafts (17) were 65% and 29%, 64% and 38%, and 51% and 37%, respectively. Rejection and infection were the major causes of graft failure. Of the 86 survivors, 67 (78%) are alive with functioning intestinal grafts on an unrestricted oral diet; 10 (12%) require partial TPN; and 9 (10%) resumed TPN after graft removal.
Symposium participants spent a great deal of time discussing when intestinal transplantation should be attempted and in which patients. Based on 1992 Medicare data, about 40,000 patients were on home TPN in the United States, of whom 15,000 suffered from intestinal failure. Because TPN is a safe and reliable therapy for most of these patients, intestinal transplantation should be considered only when patients develop definite or impending TPN-induced liver failure, major vessel thrombosis, or multiple episodes of sepsis. Transplant surgeons, however, stressed that early referral of patients is important to avoid mortality during the waiting period before transplantation and during the complicated recovery after transplantation. To make intestinal transplantation an alternative to TPN, much greater efforts need to be made by basic scientists and clinicians in the coming years. The next symposium will take place in Cambridge, England, in 1997.
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MORE ABOUT TOTAL PARENTERAL NUTRITION Total parenteral nutrition (TPN) is a treatment for patients who have lost absorptive function of the small bowel owing to massive enteric resection or abnormal intestinal motility. Since the early 1970s, the number of patients on TPN has increased rapidly due to refinements in the delivery system and the technique. TPN is now administered to most patients at home. Although TPN is a safe therapeutic modality, it is not without risk, particularly in patients who require TPN on a life-long basis. Risks include blood vessel thrombosis, bone disease, line infection and sepsis, and liver failure. In Europe, 2-4 patients per million population receive home TPN each year; 50% of these individuals require TPN permanently. See related article on Tube Feeding. |
Satoru Todo, MD
Professor of Surgery
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania
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