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Early living related segmental intestinal transplantation for trauma-induced ultra-short gut syndrome
Early Living Related Segmental Intestinal Transplantation for TraumaInduced Ultra-Short Gut Syndrome L. Cicalese, P. Sileri, C. Rastellini, H. Abcarian, and E. Benedetti
E
XTENSIVE INTESTINAL resection following massive abdominal trauma can lead to irreversible intestinal failure (IF). Cadaveric small bowel transplantation (SBTx) is limited by a high rate of rejection and infectious complications.1,2 Recently a standardized technique for living related segmental SBTx (LRSBTx) has been developed.3,4 This elective procedure allows shortening of the waiting time, thus reducing TPN-related complications in trauma victims who are often healthy individuals. The segmental graft is obtained from healthy and stable donors, can be adequately decontaminated, and can be accommodated even in a severely retracted abdominal cavity. Furthermore, LRSBTx offers immunological advantages since optimal HLA matching can be often obtained from family members. PATIENTS AND METHODS Three male trauma victims, one Caucasian, one African American, one native American, with an age ranging between 27 and 30 years and with consequent total enterectomies and IF, underwent LRSBTx at our institution. In two cases the trauma was sustained by gunshot wound, while in the third patient was secondary to motor vehicle accident. The ultrashort segment of remaining bowel consisted of the second portion of the duodenum and the sigmoid colon in all these patients. All recipients had incipient cholestasis from TPN and/or numerous line sepsis episodes. All donors were ABO compatible with excellent HLA match. A segment of 180 to 200 cm of ileum was harvested and transplanted, anastomosing the ileocolic artery and vein to the infrarenal aorta and vena cava, with a cold ischemia time of less than 10 minutes and a warm ischemia time of 30 to 40 minutes. Immunosuppression regimen consisted of oral tacrolimus, prednisone, and IV induction with ATG until tacrolimus levels were therapeutic. Serial biopsies were performed to evaluate rejection or viral infections through a temporary loop ileostomy.
RESULTS
The postoperative course was uneventful for all donors. All the recipients are currently alive and well (mean follow-up
0041-1345/02/$–see front matter PII S0041-1345(02)02667-2 914
of 27.3 months, range 12 to 41 months). All three patients are off TPN and IV fluids and are tolerating an oral diet with no limitations on daily activity. In all cases the liver dysfunction was completely reversed. All biopsies were negative for rejection. One patient developed CMV enteritis and another developed CMV gastritis that were both successfully treated with a short course of ganciclovir. There were no bacterial or fungal infections documented.
CONCLUSIONS
Isolated LRSBTx can provide complete rehabilitation for patients with IF for trauma. Our approach advises that the risk of acute rejection and infections is greatly reduced when compared to cadaveric SBTx. This elective transplant can be offered early in optimally matched donor/recipient combinations when the condition of the recipient is optimal and before life-threatening TPN-related complications develop.
REFERENCES 1. Abu Elmagd K, Rejes J, Bond G, et al: Ann Surg 234:404, 2001 2. Cicalese L, Sileri P, Green M, et al: Transplantation 71:1414, 2001 3. Cicalese L, Rastellini C, Sileri P, et al: J Gastrointest Surg 5:168, 2001 4. Gruessner RW, Sharp HL: Transplantation 64:1605, 1997
From the University of Illinois at Chicago, Transplant Surgery, Chicago, Illinois, USA. Address reprint requests to Luca Cicalese, MD, Director Intestinal Transplant Program, University of Illinois at Chicago, Division of Transplantation, 840 South Wood Street, Chicago, IL 60612. E-mail: [email protected]
© 2002 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 34, 914 (2002)
E
XTENSIVE INTESTINAL resection following massive abdominal trauma can lead to irreversible intestinal failure (IF). Cadaveric small bowel transplantation (SBTx) is limited by a high rate of rejection and infectious complications.1,2 Recently a standardized technique for living related segmental SBTx (LRSBTx) has been developed.3,4 This elective procedure allows shortening of the waiting time, thus reducing TPN-related complications in trauma victims who are often healthy individuals. The segmental graft is obtained from healthy and stable donors, can be adequately decontaminated, and can be accommodated even in a severely retracted abdominal cavity. Furthermore, LRSBTx offers immunological advantages since optimal HLA matching can be often obtained from family members. PATIENTS AND METHODS Three male trauma victims, one Caucasian, one African American, one native American, with an age ranging between 27 and 30 years and with consequent total enterectomies and IF, underwent LRSBTx at our institution. In two cases the trauma was sustained by gunshot wound, while in the third patient was secondary to motor vehicle accident. The ultrashort segment of remaining bowel consisted of the second portion of the duodenum and the sigmoid colon in all these patients. All recipients had incipient cholestasis from TPN and/or numerous line sepsis episodes. All donors were ABO compatible with excellent HLA match. A segment of 180 to 200 cm of ileum was harvested and transplanted, anastomosing the ileocolic artery and vein to the infrarenal aorta and vena cava, with a cold ischemia time of less than 10 minutes and a warm ischemia time of 30 to 40 minutes. Immunosuppression regimen consisted of oral tacrolimus, prednisone, and IV induction with ATG until tacrolimus levels were therapeutic. Serial biopsies were performed to evaluate rejection or viral infections through a temporary loop ileostomy.
RESULTS
The postoperative course was uneventful for all donors. All the recipients are currently alive and well (mean follow-up
0041-1345/02/$–see front matter PII S0041-1345(02)02667-2 914
of 27.3 months, range 12 to 41 months). All three patients are off TPN and IV fluids and are tolerating an oral diet with no limitations on daily activity. In all cases the liver dysfunction was completely reversed. All biopsies were negative for rejection. One patient developed CMV enteritis and another developed CMV gastritis that were both successfully treated with a short course of ganciclovir. There were no bacterial or fungal infections documented.
CONCLUSIONS
Isolated LRSBTx can provide complete rehabilitation for patients with IF for trauma. Our approach advises that the risk of acute rejection and infections is greatly reduced when compared to cadaveric SBTx. This elective transplant can be offered early in optimally matched donor/recipient combinations when the condition of the recipient is optimal and before life-threatening TPN-related complications develop.
REFERENCES 1. Abu Elmagd K, Rejes J, Bond G, et al: Ann Surg 234:404, 2001 2. Cicalese L, Sileri P, Green M, et al: Transplantation 71:1414, 2001 3. Cicalese L, Rastellini C, Sileri P, et al: J Gastrointest Surg 5:168, 2001 4. Gruessner RW, Sharp HL: Transplantation 64:1605, 1997
From the University of Illinois at Chicago, Transplant Surgery, Chicago, Illinois, USA. Address reprint requests to Luca Cicalese, MD, Director Intestinal Transplant Program, University of Illinois at Chicago, Division of Transplantation, 840 South Wood Street, Chicago, IL 60612. E-mail: [email protected]
© 2002 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 34, 914 (2002)