Intestinal Transplantation

In some patients with irreversible intestinal failure, intestinal transplantation can be considered as an alternative to long-term PN. The first intestinal transplantation in humans was undertaken in the early 1960s. Limitations in technical expertise and immu-nosuppressive therapy meant that none of the original patients survived beyond 76 days. From 1985 to 1990, a series of 20 patients were given cyclosporine but only 2 patients were able to resume normal nutrition and most of the grafts failed. The development of new immunosuppressive agents, particularly tacroli-mus, resulted in renewed interest in intestinal transplantation. Furthermore, since 1990, there has been greater standardization of patient selection, operative procedures, and postoperative care mainly in centers specializing in intestinal transplantation. The total international experience is still limited, involving less than 1000 transplants by 2004 (some of the transplants were isolated intestinal grafts, others were intestinal-liver transplants, and the remaining few were multivisceral transplants that included the intestine). Better graft and patient survival rates have been reported in the more experienced centers. In a series of 165 intestinal transplants at the University of Pittsburgh, patient survival was reported to be more than 75% at lyear, 54% at 5years, and 42% at 10 years. More than 90% of patients resumed an unrestricted oral diet.

It appears that intestinal transplantation has become a realistic life-saving option for some people who cannot be maintained on HPN. However, it is not yet the treatment of choice in patients who can be successfully maintained on HPN without noteworthy complications. Nor is it the treatment of choice in patients who are likely to deteriorate rapidly from other causes, such as aggressive multisystem disease, or likely to improve so that they can resume oral nutrition (e.g., patients with healing intestinal fistula or those with short bowel syndrome, in which benefits from intestinal adaptation may continue for up to 1-3 years). A better understanding of the immune response to the transplanted intestine and better immunosuppressive therapy, surgical techniques, and postoperative management are required. Appropriate selection and referral of patients to specialist centers are also important criteria that affect clinical outcomes.

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