Intestinal transplantation: Laboratory experience and report of a clinical case

Intestinal Transplantation: Laboratory Experience and Report of a Clinical Case FIKRI ALICAN, JAMES

MUKADDER JOSEPH PATRICIA

E. VARNER,

Massive resection of jejunum and ileum is frequently performed in mesenteric vascular occlusion, strangulation obstruction due to volvu1us, congenital malformations, regional enteritis, abdominal trauma, or extensive neoplasm. Normally the small intestine has a large functional reserve. It has been known for a long time that dogs can gradually return to a condition of practically normal weight and metabolism after removal of 50 per cent of their small intestine [I]. Recent studies demonstrated that resections up to 80 per cent in dogs are usually compatible with life [2,3]. Consistent with these experimental observations is the finding that good nutrition is also maintained in man with resection of up to 70 per cent of the small bowel [4,5]. Resection of the ileocecal sphincter and the ascending colon in addition to massive small bowel resection adds to morbidity [6], and the nutrition in such cases is impaired by only 50 to 60 per cent small intestine resection [4]. A number of patients survived resection of all but a few inches of the small intestine [7-111. In such patients diarrhea, steatorrhea, hypoproteinemia, weight loss, and mineral and vitamin deficiencies are difficult to manage. Nevertheless, treatment based on assessment of absorption defects and nutritional needs occasionally makes possible an existence in reasonably good health. After extensive resection, compensatory changes occurring in the remaining portion of the small intestine result in increase of the absorptive capacity [1,12-l 71. The diarrhea and steatorrhea which ordinarily follow massive small bowel resection gradually lessen. The compensation appears to be due to an increase in the number of absorptive From the Department of Surgery. University of Mississippi Medical Center, 2500 North State Street, Jackson, Mississippi 39216. This work was supported by US Public Health Service Grant Number HE 11730. Presented at the Eleventh Annual Meeting of the Society for Surgery of the Alimentary Tract, Chicago, Illinois, June 20 and 21, 1970.

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Mississippi

MD, Jackson, MD, Jackson,

C. MOYNIHAN, ANAS,

Mississippi

MD, Jackson,

CAYIRLI,

M. D. TURNER, PANDELI

MD, Jackson,

D. HARDY,

Mississippi Mississippi

MD, Jackson,

PhD, Jackson,

Mississippi

MD, Jackson,

Mississippi

Mississippi

sites and a greater villous surface area [14]. There is an increase in small bowel diameter and intestinal weight per unit length, accompanied by hypertrophy of the villi [17]. Recently, reversed segments of small bowel have been used in human subjects and in some instances this procedure has helped to slow small bowel transit time with further improvement in absorption [15]. However standardization of the length of the segment to be reversed has to be worked out [ 18 ] and the results of this procedure are as yet unpredictable [19]. Total resection of the jejunum and ileum, on the other hand, is an entirely different situation. For all practical purposes the colon is incapable of assuming absorptive functions of the small intestine. “Intestinalization” of the large bowel with compensatory increased capacity for absorption has at times been a matter of conjecture. However, this has never been substantiated by either metabolic studies or biopsy specimens [15,17]. Absence of the entire mesenteric small intestine is thus incompatible with long-term survival. A surgeon is apt to encounter occasionally at laparotomy dead bowel from the ligament of Treitz down to or beyond the ileocecal valve. In such cases, quite a few surgeons are reluctant to resect the entire small intestine and will accept certain death for the patient by closing the abdomen. The alternative, resection of the entire necrotic small bowel, will obviate immediate death of the patient, but will put the surgical team in a distressing position because subsequently a satisfactory substitute for the function of this vital organ is not available. Nevertheless, efforts involved in allografting intestine may be well worth the trouble, especially since the prospective recipient can now be supported for a long period of time with intravenous alimentation. It is true that the hope for outstanding success appears to be meager at the present time. However, continued The

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Intestinal Transplantation investigations at both the laboratory and the clinical level are necessary if intestinal transplantation is to be advanced. In this paper we will briefly review experimental work performed by others, along with our own laboratory experience in intestinal transplantation, and report a clinical case. Laboratory Experience with Intestinal Transplantation

Effects of Lymphatic Interruption and Denervation. In 1959 Lillehei and his associates [20,21] removed the entire small bowel in dogs, save for the first few centimeters of duodenum, and then replanted it after various periods of in vitro storage. A single arterial and venous anastomosis restored the circulation and intestinal anastomoses, restored normal continuity. Many of their dogs survived for weeks or months after replantation, indicating that the bowel could survive complete severance of all connections with the central nervous and lymphatic systems and that anastomoses of the superior mesenteric vessels, especially those of the veins, would remain open. Although the dogs were subject to diarrhea in the immediate postoperative period, by the tenth day the stools appeared normal and all dogs regained their preoperative weight after recovery from the operation. These workers also demonstrated the ability of the totally severed lymghatics of the replanted canine small bowel to regenerate promptly and resume full functional capacity by the use of vital dye and radiographic technics [ 211. Kocandrle, Harttuin, and Prohaska [22] demonstrated in dogs with intestinal replants that at the end of the fourth postoperative week normal sized channels delivered the lymph from the replanted intestine into the thoracic duct. We performed replantation experiments using the same technic as a preparation for small intestinal homotransplantation experiments. After an initially high mortality rate for technical reasons, we obtained several long-term survivors. In these dogs diarrhea was commonly observed only during the first and second postoperative weeks ; thereafter, the dogs appeared normal in every way and began to gain weight. At “second look” operations from five months to a year postoperatively we noted fully regenerated intestinal lymphatics ; biopsies of the intestinal wall revealed normal histology. Ballinger, Christy, and Ashby [23] during their replantation experiments on dogs observed decreased absorption of fat, roentgenologic alterations, and loss of mucosa and villi determined by biopsy. They did not consider recovery of these dogs complete for at least six months. These changes were not believed to be due to ischemia or Volume 121, February 1971

failure of lymphatic regeneration since denervation of the canine small intestine without ischemia produced changes identical to those observed after replantation. It thus appears that although the removal and replacement of the entire small intestine in the dog is followed eventually by complete lymphatic regeneration and by grossly normal daily activity and long-term survival, various degrees of anatomic and functional alterations should be expected for several months after the operation. Storage. Interruption of all circulation to the small bowel for two hours is tolerated if the bowel is allowed to cool to room temperature (25 to 28”~). If, however, the bowel is cooled to 5”c, then it is safe to interrupt its circulation completely for at least five hours [20]. In several dogs we have rapidly cooled the resected entire small intestine by perfusion through its artery with cold electrolyte solution and held it in the refrigerator for three hours before replantation. The bowel remained viable and the dogs survived the procedure. Eyal and his associates [24] transplanted segments of small bowel into the neck of dogs after in vitro preservation under various conditions. In bowel preserved for twenty-four hours simply in cold solution hemorrhagic necrosis developed upon revascularization. Addition of chlorpromazine to the initial perfusate and to the storage solution allowed successful preservation at 4”~ for up to forty-eight hours. Addition of hyperbaric oxygen (7.9 atm) resulted in improved preservation. Although these authors reported a high rate of success with these preserved homografts, viability was evaluated by gross and histologic study of the graft and for only up to four days. Physiologic integrity of replanted tissue was not tested. Austen and McLaughlin [25] found that nonpulsatile blood flow to the isolated bowel in vitro resulted in impairment of metabolic function and gross changes in the bowel mesentery within six hours. On the other hand, pulsatile flow did not seem to result in marked impairment of function or gross changes in the mesentery of the isolated bowel after periods of perfusion of up to eighteen hours. Iijima and Salerno [26] reported a number of dogs surviving replantation of small bowel after normothermic perfusion with fresh autologous blood and Ringer’s solution for five hours. We have stored two allografts for twenty-four hours by continuous hypothermic homologous serum perfusion at 9” C (a pulsatile flow of 150 to 200 cc per minute for the entire intestine of a dog weighing 15 to 20 kg). We had previously used this method for successful twenty hour storage of the canine liver [27]. During perfusion no gross changes were noted in the bowel or its mesentery, and upon or151

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thotopic transplantation to recipients these grafts were vascularized quite well and had a normal pink color. However, they started to produce copious amounts of mucus while the intestinal anastomoses were being performed and peristalsis was greatly increased. The recipients died within a few hours from loss of liters of fluid, electrolyte, and protein. This phenomenon is an ominous sign implying inadequate storage. From the results of these studies one might draw the conclusion that a safe and uniformly applicable method of in vitro storage of small intestine beyond a few hours is not yet available. However, the fact that such grafts fully retain their viability for three to five hours if cooled immediately after procurement would appear to afford sufficient time to make clinical cadaver transplantation technically feasible in most cases. Several Rejection and Immunosuppression. years ago Lillehei’s groups, using a technic similar to their replantation technic, performed intestinal allotransplantation in twenty-four dogs. The animals were paired and the entire small bowel of one was exchanged for that of its partner [28,29]. No attempt was made at suppression of the immune response. Only less than half of these dogs lived long enough for rejection to be considered. These survivors died in a characteristic, rather precipitous fashion between the sixth and ninth day, but even in these dogs no tissue findings of significance were noted to explain their death. The allografts appeared viable ; there were some polymorphonuclear cell infiltrations but no evidence of extensive round or plasma cell infiltration or small vessel thrombosis. Anastomoses were intact with normal signs of healing. These investigators have speculated that death might be a result of the homograft (a large mass of antigens) causing a profound metabolic upset in the host before characteristic tissue changes could occur-the so-called runt phenomenon. Barnett, Truett, and Stone [SO] in our laboratory transplanted a short segment of canine small intestine heterotopically in the abdomen ; they closed one end and brought out the other end as an ileostomy. These animals without immunosuppression lived seven to nine days. The authors also stressed the absence of round cell infiltration that characterized the rejection phenomenon as manifest in other transplanted organs. Preston and his associates [31,32] also performed heterotopic allotransplantation of short segments of small intestine to the neck or abdominal cavity (with restoration of intestinal continuity) of recipient dogs and reported a survival of five to twelve days (mean eight days) without treatment. Contrary to the previous experience, however, they observed as 152

an earliest indication of rejection a round cell infiltration and hemorrhage into the mucus membrane, with sloughing of the superficial layers of epithelium. Later, edema and perivascular round cell infiltration of the muscular and serosal layers had occurred. After gaining technical proficiency with replantation experiments, we have performed exchange transplantation of the entire jejunoileum on nine pairs of dogs. (Figures 1 and 2.) Intestinal continuity was immediately restored by a duodenojejunal and ileocecal anastomosis. Immunosuppression was not used, to permit study of the full picture of homograft reaction. Death of ten dogs was attributed to technical causes. Eight dogs lived an average of thirteen days (seven, eight, eight, ten, eleven, thirteen, fourteen, and thirty-one days, respectively). Diarrhea occurring after operation was common, but the animals usually ate normally. However, death occurred rather precipitously and was sometimes preceded for one or two days by bloody diarrhea and abdominal distention. The longest survivor (Figure 3) gradually lost weight and became anemic, although he had appeared to have normal appetite for a month. At autopsy the vascular anastomoses were patent in all dogs. Grossly, the most characteristic finding was the significant enlargement of the donor mesentery with its lymph nodes which were transplanted along with the graft. From this finding and from the somewhat prolonged survival of the recipients, we initially had the impression that the massive amount of antigenic tissue involved in these allografts was rejected sluggishly and that graft versus host reaction might be important. However, microscopic study of the biopsy specimens revealed significant degrees of round cell infiltration with destruction of mucosa on all grafts. Moreover, the enlargement of the donor mesenteric lymph nodes proved to represent edema with dilatation of lymphatic sinuses accompanied by moderate to severe degrees of depletion of lymphocytes. It would seem therefore that intestinal allografts are subject to the same mode of rejection as most other organs : increasing degrees of infiltration with infection, and necrosis as an end stage. None of these findings was present in our replantation experiments. Attempts at suppressing immune response in intestinal transplantation have met with limited success. Preston and his associates used azathioprine and prednisone after allotransplantation of short intestinal segments with restoration of continuity. Average survival was thirty-nine days [31,32]. Rejection occurred eventually. One of their dogs remained healthy for six months [32] ; The

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Figure 1. Transplantation of the entire jejunoiieum in the dog. The graft was washed and cooled by perfusion with lactated Ringer’s solution (at $4” C) through its artery. The superior mesenteric artery of the graft is anastomosed to the stump of the superior mesenteric artery in the recipient. The superior mesenteric vein, seen on the right of the artery, is to be anastomosed next. Note that the large lymph nodes on the mesentery of the graft (indicated by the arrow) are transplanted along with the intestine.

Transplantation

Figure 2. Blood flow is restored by removing the vascular clamps. Pulsations of the arteries and peristalsis begin and the graft immediately turns from paper white into a healthy oink co/or.

however, an atrophic graft which had caused intestinal obstruction was finally removed 204 days after transplantation. A disconcerting aspect of this subject is the occurrence of atrophy and absorption in some of these allografts [30-321, with resultant intestinal obstruction, when they remain long enough in the recipient. On the other hand, autografts do not undergo atrophy. Recently Ruiz, Uchida, and Lillehei [33] have been consistently able to keep dogs with orthotopic intestinal allografts alive three weeks or more using immunosuppression. They now observe classic histologic signs of rejection in the allograft. Moreover, survival for as long as five weeks allowed them to study carbohydrate, protein, and fat metabolism. They found serious impairment in the absorption of these foodstuffs. Also, in contrast to their findings with intestinal replants, they noted that lymphatic connections to the allograft do not regenerate in the first two or three weeks. These authors concluded that intestine acts similarly to other allografts in eliciting rejection and responding to immunosuppression, albeit with a serious impairment of function for an undetermined period of time. Case Report

History. was evaluated Volume

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The patient, an eight year old white boy, by a neurologist for abdominal pain and

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Figure 3. The longest surviving dog without immunosuppression. The picture was taken four weeks after orthotopic allotransplantation of the entire jejunoileum. The dog gradually lost weight and became anemic. 153

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Figure 4. Operation on the Approximately three feet of continuation of the superior companying vein) beyond its pedicle of the graft.

living donor (patient’s mother). ileum was removed using the mesenteric artery (with its acifeocolic branch as the vascular

vomiting in July 1966. This pain was also associated with headaches but no actual focal seizure activity. A diagnosis of “abdominal epilepsy” was made and obtained at the time of admission to the University Hospital in May 1969. At that time he presented with abdominal pain, nausea, and vomiting of twenty-four hours’ duration. Bowel movements had been normal and he had no fever. He was hypothermic and abdominal examination revealed a mild diffuse tenderness without rebound. The abdomen was soft, bowel sounds were hypoactive, and no mass was palpable. Rectal examination was noncontributory. X-ray films of the abdomen showed the bowel air pattern to be one of ileus. He was admitted to the pediatric service and his condition deteriorated rapidly ; he went into profound shock approximately two hours after admission. Abdominal tap revealed bloody foul-smelling fluid. He was treated with steroids, antibiotics, blood, and fluid replacement in preparation for surgery. At laparotomy the entire small bowel from the ligament of Treitz to the ileocecal valve was gangrenous, secondary to strangulation by a mesenteric band, and was resected. Duodenocecostomy was performed. In the postoperative period, the patient was slow to respond mentally. However, by the end of the first postoperative week he was alert and reactive and seemed to be out of danger with respect to the lethal effect of strangulation obstruction. Steroid dosage was decreased and he was started on a regimen of total intravenous nutrition 154

through an indwelling catheter inserted through an external jugular vein and directed into the superior vena cava. Composition of the hypertonic infusate used was 22 per cent glucose, 5 per cent protein hydrolysate, electrolytes, and multivitamins, With this method all essential nutrients could be provided without exceeding daily fluid requirements [34]. Throughout the hospital course antibiotic treatment was necessary because of recurrent infections of the respiratory, alimentary, and urinary tracts with such organisms as Staphylococcus aureus, Pseudomonas, Proteus, and Escherichia coli. Attempts at oral feeding were generally unsatisfactory, resulting in either vomiting or profuse diarrhea. Decision for Transplantation. In early June the child began running a septic course secondary to an infected catheter site. The catheter was removed and inserted through a branch of the subclavian vein. Thereafter, this was necessary on numerous occasions throughout his course because of sepsis. There came a time when even the inferior vena caval system had to be used despite its obvious disadvantages. Although it was rather easy to provide this patient with an adequate amount of calories without wateroverloading, it appeared that the infection problem with the catheters would soon be a deterrent to the continuation of total intravenous nutrition. The question of intestinal allotransplantation naturally arose. Two months before this child was operated on we had seen another such patient who was an adult and both the small and large intestine had to be removed as an emergency procedure; he had died a few days later. This child was in better general condition than the other candidate and had an intact colon, We were aware of the fact that very few clinical transplants had been performed [35,36] and that the results had been extremely poor. Similarly, laboratory experience had been unfavorable. Nevertheless, to deny an intestinal transplant to this child after total intravenous nutrition was no longer a possibility would mean his death within a short time. If a living adult donor with high histocompatibility would be willing to sacrifice a small portion (about 3 feet) of his small intestine, this length would mean considerable absorptive surface for this small patient. The full Committee on Human Investigation met and it was agreed unanimously that a small bowel transplant would be in order in this case. Tissue typing was performed with the child’s mother proving to be a Class B match on the Terasaki scale. The parents were fully aware of the risk to the child (very definite) and to the mother (negligible) and of the limited promise of long-term success of the transplant. Severe pneumonia associated with congestive heart failure developed on June 21, 1969 and the patient was digitalized accordingly. He was also found to have monilial sepsis, and treatment with Amphotericin B was instituted. In early July he was afebrile with a slight gain, but he continued to be intolerant of oral feeding. Barium enema and upper gastrointestinal series on July 12 showed essentially normal findings save for the absence of the entire jejunoileum. The barium enema showed reflux into the stomach. Gastric analysis reThe American

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vealed 1.5 mEq per hour. Left hip and inguinal pain and swelling developed in early August 1969, secondary to thrombophlebitis of the left femoral vein at the catheter site. Again he became septic and was treated with massive doses of antibiotics and removal and replacement of the catheter at another site. During the first week of September his general condition was stable, he was afebrile, and allotransplantation was performed on September 9,1969. The Transplantation Procedure. First the abdomen of the mother was opened through a right paramedian incision and the blood supply of the small bowel carefully examined. After dissection at the base of the mesentery, the continuation of the superior mesenteric artery with its accompanying vein beyond their ileocolic branch was isolated. These vessels supplied about 3 feet of ileum, which began 18 inches from the cecum and ran proximally over the 3 foot distance. (Figure 4.) When all had been “skeletonized” and was ready, this ileal segment in the territory of the selected vessels was divided at both ends and the mother’s ileum was reanastomosed end to end. The excluded ileal segment to be used as the allograft was allowed to remain on its intact vascular pedicle until the child had been prepared in an adjacent operating room. When the recipient was ready, the graft was removed, perfused with cold lactated Ringer’s solution and transplanted. The abdomen of the recipient was opened through a long midline incision, and the colon appeared somewhat more elongated and enlarged than one would ordinarily expect. This was probably due to altered metabolism within its lumen in the form of bacterial fermentation [11,17]. The previous anastomosis between the duodenum and the ascending colon was not remarkable. Attention was turned to the location of the right hypogastric artery in the pelvis, but the structures were so fibrotic, secondary to peritonitis which he had had previously, that it would have taken an inordinate amount of time for dissection and created a lot of oozing from raw surfaces to free up and expose the hypogastric artery and iliac vein. Furthermore, the iliac vein and lower vena cava were exposed and found to be virtually completely occluded by thrombus, doubtless secondary to the femoral catheters used with hypertonic solution to feed the patient over the past several months. The thrombosis of the vena cava appeared to extend almost up to the level at which the renal veins entered the vena cava. Since it was impossible to anastomose the vein below, we decided to expose the left renal vein where it crossed the aorta and anastomose the vein of the graft to this, and the artery of the graft to the aorta of the recipient. This was eventually done. (Figure 5.) The possibility of removing the spleen and using the splenic artery and vein was considered, but it would have required much extension of the incision and considerably more dissection, A splenic vessel anastomosis would, however, have put the venous drainage from the intestinal allograft into the portal system and thus through the liver. Anastomosis of the graft vein to the renal vein was easily accomplished. The anastomosis to the aorta of Volume

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Figure 5. Operation on the recipient patient. The vein of the graft was anastomosed to the left renal vein of the recipient, and the artery of the graft was anastomosed to the aorta of the recipient.

the graft artery with interrupted fine silk sutures was unwieldy but was eventually achieved satisfactorily (the vein was about 8 mm, and the artery was less than 4 mm in diameter). There was only a brief warm ischemia time. The cold ischemia time required to suture the bowel in satisfactorily was about one hour and fifteen minutes. The allograft became pink immediately, but then became cyanotic for over an hour. Administration of Rheomacrodex” and heparin in addition to moderate selective hypothermia of the allograft gradually improved its appearance and ultimately about two hours after the anastomoses had been completed, peristalsis was going through its entire length and the color was satisfactory. Judging from subsequent reports in the literature the intra-arterial infusion of a ganglionic blocking drug might have been useful also. Nevertheless, we decided against plugging the graft into the alimentary tract of the recipient. Instead, we brought both ends of the allograft through the right upper quadrant. The abdomen was irrigated with saline solution, and neomycin was placed in the lumen of the allograft. Catheters were placed through the abdominal wall to administer Keflin@ into the peritoneal cavity intermittently. We had planned to anastomose the graft to the duodenum and colon of the recipient two or three weeks later. The patient was sent to the recovery room in good condition. Postoperatively the patient Postoperative Course. did well for four days. He was placed on an immunosuppressive regimen consisting of 3.5 mg per kg per day of azathioprine (Imuran”), 4 mg per kg per day of antilymphocytic globulin, and 1 mg per kg of prednisone four times a day. On the third postoperative day 155

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Imuran dosage was reduced to 1 mg per kg per day. Unfortunately, however, on September 18, 1969 it was noted that the stomas which pulled through the abdominal wall appeared necrotic, and questionable drainage appeared around their perimeter. The patient became toxic and was returned to the operating room with the tentative diagnosis that the graft was devitalized. The middle two thirds of the previous abdominal incision was reopened by removing the sutures. It was promptly apparent that most of the allograft was still perfused, though it did not appear really healthy. There were several spots on the bowel which appeared questionably viable. Furthermore, the mesentery was thickened and appeared unhealthy, having the general edematous appearance which we found in dogs when gut allografts were rejected. This was probably largely due to the absence of regeneration of the lymphatics. His toxic condition was probably due in considerable measure to the perforated duodenal ulcer which was found. The ulcer was closed by the method of Graham. Next, after considerable deliberation, we reluctantly decided to remove the allograft to forestall possible leakage in the future. Although gastric acidity was normal in this patient on one occasion, the finding of a perforated duodenal ulcer was most interesting in view of the demonstration of a chronic hypersecretory state in dogs after massive intestinal resection [S7-391. There is also evidence that gastric hypersecretion may occur in patients after extensive bowel resection and may require surgical correction [38]. However, another explanation in our patient would be that this condition might represent a stress ulceration, although stress ulcers usually occur in the stomach and are commonly multiple. After the second operation the wound became suppurated, requiring incision and drainage. Every effort was made to continue intravenous nutrition as well as to feed fluid nutrients to the patient. In early October his course r&idly deteriorated, associated with intraabdominal sepsis and gastrointestinal bleeding. Some degrees of hepatic and adrenal insuffitiiency may have developed before his death on October 11; 1969. Microscopic examination of the excised allograft revealed patchy necrosis of the submucosa and muscularis of the entire segment of the allograft. Many of the fat cells in the mesentery had lost their nuclei. Most of the peripheral blood vessels and lymphatics were empty but dilated. No thrombi were seen except in a few scattered mucosal and submucosal capillaries. The large vessels at the root of the mesentery were full of red cells but no thrombi were evident. In some areas there was edema, hemorrhage, and acute cellular reaction consisting largely of neutrophils along with necrosis. The pathologists did not find evidence of an advanced state of allograft rejection. Comments

Very few intestinal transplants have been performed clinically. Lillehei and his associates had to resect the necrotic small and large intestine of a forty-six year old woman from the ligament of

Treitz to the rectum due to diffuse mesenteric venous thrombosis. They later transplanted the entire jejunoileum and the ascending colon of a cadaver donor to this patient [35]. Unfortunately the patient’s pre-existing clotting problem was so extensive as to involve systemic veins as well as portal and mesenteric veins. The patient died in twelve hours. Another case was reported by Olivier and his group in Paris [36,40-421. The patient was a thirty-five year old man with Gardner’s syndrome. The small intestine and the ascending colon of the patient were removed and replaced with those of a cadaver donor. Since the graft encompassed the entire field of the main superior mesenteric vessels, vascular anastomoses were performed at the root of these structures. Thus, this procedure was truly orthotopic. The duodenum of the patient was anastomosed to the jejunal end of the graft and the transverse colon of the graft was brought out as a colostomy [40]. The patient died on the twenty-sixth day in a toxic condition [36]. The authors stressed the fact that regeneration of the lymphatics had not occurred during this time [41]. They have also described a histologic picture of rejection including infiltration with round cells of the allograft in this patient with immunosuppression [42]. During the entire management of our case we were faced with several unusual difficulties. Major problems due to infection at the catheter site for intravenous nutrition were alluded to previously. Another problem arose after the patient’s abdomen was opened to insert the allograft. Secondary to previous peritonitis and multiple catheterizations of the inferior vena cava, the patient’s fibrosis was so extensive that it was impossible to perform the procedure that we had carefully planned; suturing the arterial supply of the graft was at best a compromise procedure. Nevertheless, the ischemia time was within acceptable limits. Since the microscopic examination did not show substantial components of rejection, and the vascularization of the graft was not entirely satisfactory from the beginning, the outcome in this case should probably be attributed largely to technical factors. Recently it has been demonstrated in the animal laboratory that growth and development can be achieved by supplying basic nutrients exclusively by the intravenous route. Puppies fed entirely intravenously for 72 to 255 days with a 30 per cent solution of glucose, amino acids, electrolytes, vitamins and trace minerals outstripped in weightgain the littermates which had been fed by mouth and matched them in skeletal growth and development [43]. This method of total intravenous nutriThe

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(intravenous hyperalimentation) has also proved to be safe and effective in providing adequate nutrition without the use of fat when enteral feeding is inadequate or impossible for prolonged periods of time [ 44-481. Patients have received all required calories, nitrogen, vitamin, and minerals in specially prepared solutions exclusively by vein for periods up to 200 days [4-G]. The hypertonic nutrient solution containing 20 per cent glucose, and 5 per cent fibrin hydrolysate (Aminosol@) was administered continuously through an indwelling catheter inserted into the external jugular or subclavian vein and directed into the superior vena cava. In this way 12 to 25 gm of nitrogen and 2,300 to 4,500 calories could be delivered using fluid volumes of 2,500 to 3,000 cc. Significant complications of indwelling catheters, such as phlebitis, thrombosis, embolism, and sepsis have been rare [48]. In a few patients, however, febrile episodes suggesting cannula sepsis occurred between the thirty-fifth and fortieth days of catheterization, and blood cultures revealed Candida fungemia and staphylococcal bacteremia [GS]. It is recommended that the indwelling catheter be removed after thirty days and, if continued intravenous nutrition is required, the catheter should be reinserted in the opposite jugular vein. As an alternative to high caloric parenteral nutrition in cases of severe malabsorption, the potential usefulness of a fortified elemental aerospace diet (a chemically defined osmotically adjustable diet) warrants further investigation [49]. A surgeon will occasionally find himself responsible for the nutrition of a patient in whom oral feeding is futile for a lifetime. An allograft in such a situation clearly has the potential of being the most straightforward remedy. It appears that when clinical intestinal transplantation is advanced to a level comparable to that of kidney transplantation, the improved methods of total intravenous nutrition will represent as useful an adjunct as the artificial kidney is to renal transplantation.

tion

Summary

The experimental intestinal transplantation in our laboratory and elsewhere is briefly reviewed. Replantation of the entire jejunoileum is compatible with long-term survival of experimental animals. Lymphatic pathways severed during the procedure fully regenerated within a few weeks. Contrary to the implication of earlier studies on this subject, it is now believed that intestinal allografts are rejected in the same manner as other organs, and the rejection response is definitely mitigated by immunosuppressive drugs. There is no Volume 121,

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conclusive evidence of a graft versus host reaction despite the fact that transplantation of the entire jejunoileum represents a large antigenic mass and transplantation of many mesenteric lymph nodes. The time necessary for regeneration of lymphatic pathways after allotransplantation is different from that after replantation. In an eight year old boy with surgical removal of the entire jejunum and ileum, repeated problems with infection at catheter sites precluded intravenous feeding after four months. A 3 foot length of terminal ileum from his mother (a class B match) was transplanted, both ostia being opened as mucous fistulas to the abdominal wall. On the seventh day the recipient was explored because of the necrotic appearance of the stomas and a perforated duodenal ulcer. The allograft was precariously perfused and of questionable viability. It was removed to forestall possible further intraabdominal complications. Microscopic examination revealed extensive ischemic necrosis. The large vessels were open but the small vessels contained little blood. It was the opinion of the pathologist that the alterations found represented acute rejection, but we believe that limited arterial perfusion may have contributed substantially to the atrophic changes observed. References 1. Flint JM: The effect of extensive resections of the small intestine. Bull Johns Hopkins Hosp 23: 127, 1912. 2. Grenier JF, Crevoisier R, Sava G, Kachelhoffer J, Weiss AG: Les resections massives d’intestin grele etude experimentale de leurs repercussions. Ann Chir 23: 599, 1969. 3. Clatworthy HW, Jr, Saleeby R, Lovingood C: Extensive small bowel resection in young dogs. Its effect on growth and development. Surgery 32: 341, 1952. 4. Chen KM: Massive resection of the small intestine. Surgery 65: 931, 1969. 5. Rickham PP: Massive small intestinal resection in newborn infants. Hunterian lecture delivered on 13th of April 1967. Ann Roy Coil Surg Eng 41: 480, 1967. 6. Berroya RB, Janelli DE, Paul GJ, Kashiwabara H, Smith RF: Massive resection of the small intestine. Survival of two patients with less than two feet (60 cm) of small bowel. lnternat Surg 52: 277, 1969. 7. Delagarde P, Magnier F, Meunier M: Les “Amputes” de I’intestin la survie apres les resections etendues. Ann Chir 21: 289, 1967. 8. Meyer HW: Extensive resection of small and large intestine: a further twenty-two year follow-up report. Ann Surg 168: 287, 1968. 9. Berman LG, Ulevitch H, Hat? HH, Lemish S: Metabolic studies of an unusual case of survival following resection of all but eighteen inches of small intestine. Ann Surg 132: 64, 1950. 10. Winawer SJ, Broitmaq SA, Wolochow DA, Osborne MP, Zamcheck N: Successful management of massive small-bowel resection based on assessment of absorption defects and nutritional needs. New Eng J Med 274: 72, 1966. 11. Anderson CM: Long-term survival with six inches of small intestine. Brit Med J 1: 419, 1965. 157

Alican et al 12. Althausen TL, Doig RK, Uyeyana K, Weiden S: Digestion and absorption after massive resection of the small intestine. II. Recovery of the absorptive function as shown by intestinal absorption test in two patients and a consideration of compensatory mechanisms. Gastroenterology 16: 126, 1950. 13. Porus RL: Epithelial hyperplasia following massive small bowel resection in man. Gastroenterology 48: 753, 1965. 14. Weinstein LD, Shoemaker CP, Hersh T, Wright HK: Enhanced intestinal absorption after small bowel resection in man. Arch Surg 99: 560, 1969. 15. Beaudry R, Butson ARC, Harrison J, Finlay JM: Survival after massive small bowel resection. Canad Med Ass J 97: 1483, 1967. 16. Dowling RH: Compensatory changes in intestinal absorption. Brit Med Bull 23: 275, 1967. 17. Wilmore D: Short bowel syndrome. A comprehensive approach to patient management. I. Pathophysiology following massive intestinal resection. J Kansas Med Sot 70: 233, 1969. 18. Stahlgren LH, Umana G, Roy R, Donnelly J: A study of intestinal absorption in dogs following massive small intestinal resection and insertion of an antiperistaltic segment. Ann Surg 156: 482, 1962. 19. Wilmore DW, Johnson CJ: Metabolic effects of small bowel reversal in treatment of the short bowel syndrome. Arch Surg 97: 784, 1969. 20. Lillehei RC, Goott B, Miller FA: The physiological response of the small bowel of the dog to ischemia including prolonged in vitro preservation of the bowel with successful replacement and survival. Ann Surg 150: 543, 1959. 21. Goott B, Lillehei RC, Miller FA: Mesenteric lymphatic regeneration after autografts of small bowel in dogs. Surgery 48: 571, 1960. 22. Kocandrle V, Harttuin E, Prohaska JV: Regeneration of the lymphatics after autotransplantation, and homotransplantation of the entire small intestine. Surg Gvnec Obstet 122: 587, 1966. 23. Ballinger WF, Christy MG, Ashby WB: Autotransplantation of the small intestine. The effect of denervation. Surgery 52: 151, 1962. 24. Eyal Z, Manax WG, Bloch JH, Lillehei RC: Successful in vitro preservation of the small bowel including maintenance of mucosal integrity with chlorpromazine, hypothermia, and hyperbaric oxygenation. Surgery 57: 259,1965. 25. Austen WG, McLaughlin ED: In vitro small bowel perfusion. Surg Forum 16: 359, 1965. 26. lijima K, Salerno RA: Survival of small intestine following excision, perfusion and autotransplantation. Ann Surg 166: 968, 1967. 27. Turner MD, Alican F: Successful 20-hour storage of the canine liver by continuous hypothermic perfusion. Cryobiology 6: 293, 1970. 28. Lillehei RC, Gooth B, Miller FA: Homografts of the small bowel. Surg Forum 10: 197, 1960. 29. Lillehei RC, Longerbeam JK, Goott B, Goldberg S, Scott WR: Gastrointestinal transplantation. Surg Clin N Amer 42: 1191, 1962. 30. Barnett WO, Truett G, Stone J: Experimental smallbowel homografts. Amer J Digest Dis 7: 833, 1962. 31. Preston FW, Macalalad F, Graber R, Jackson EJ, Sporn J: Function and survival of jejunal homotransplants in dogs with and without immunosuppressive treatment. Transplantation 3: 224, 1965. 32. Preston FW, Macalalad F, Wachowski TJ, Randolph DA, Apostol JV: Survival of homografts of the intestine with and without immunosuppression. Surgery 60: 1203, 1966. 33. Ruiz JO, Uchida H, Lillehei RC: The canine orthotopic small bowel allotransplantation with special reference to absorption studies. JAMA 212: 863, 1970. 34. Dudrick SJ, Wilmore DW, Vars HM, Rhoads J: Long-term 15s

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total parenteral nutrition balance. Surgery 64: 134, 1968. Lellehei RC, ldezuki Y, Feemster JA, Dietzman RH, Kelly WD, Merkel FK, Goetz FC, Lyons GW, Manax WG: Transplantation of stomach, intestine and pancreas: experimental and clinical observation. Surgery 62: 721, 1967. Olivier C: Homotransplantation orthotopiaue de I’intestin grele et des colons droit et transverse’ chez I’homme. J Chir (Paris) 98: 323, 1969. Lilly JR, Randolph JG: Effects of vagotomy and pyloroplasty on growth and survival in enterectomized puppies. Surg Forum 18: 307, 1967. Windsor CW, Fejfar J, Woodward DAK: Gastric secretion after massive small bowel resection. Gut 10: 779, 1969. Frederick PL, Sizer JS, Osborne MP: Relation of massive bowel resection to gastric secretion. N Eng J Med 272: 509, 1965. Olivier Cl, Rettori R, Olivier C: La technique chirurgicale des transplantations orthotopiques du grele. J Chir (Paris) 98: 331, 1969. Olivier C, Olivier C, Rettori R: Les consequences de I’interruption lymphatique et de I’enervation lors de I’homotransplantation totale du grele chez I’homme. J Chir (Paris) 98: 341, 1969. _-. Olivier C, Amiel J, Schwarzenberg L: Problemes immunologiques et reaction de reiet au tours de I’homotransplantation humaine d’lntestin grele. J Chir (Paris) 98: 385, 1969. Dudrick SJ, Wilmore DW, Vars HM: Long-term total parenteral nutrition with growth in puppies and positive nitrogen balance in patients. Surg Forum 18: 356, 1967. Wilmore DW, Dudrick SJ, Vars HM. Rhoads JE: Longterm intravenous hyperalimentation. Fed Proc 27: 486, 1968. Wilmore DW, Dudrick SJ: Growth and development of an infant receiving all nutrients exclusively by vein. JAMA 203: 860. 1968. Wilmore DW, Groff DB, Bishop HC, Dudrick SJ: Total parenteral nutrition in infants with catastrophic gastrointestinal anomalies. J Pediat Surg 4: 181, 1969. Wilmore DW, Dudrick SJ: Safe long-term venous catheterization. ‘Arch Surg 98: 256, 1969. Filler RM, Eraklis AJ, Rubin VG, Das JB: Long-term total parenteral nutrition in infants. New Eng J Med 281:

589, 1969. 49.

Stephens RV, Thompson WR, Randall HT: The use of a fortified elemental aerospace diet in the management of nutrition following massive small bowel resection. Surg Forum 19: 381, 1968.

Discussion FREDERICK W. PRESTON (Skokie, Ill) : One of the earliest papers on intestinal transplantation presented from work done at the University of Mississippi* stimulated us to transplant segments of intestine in dogs. Roentgenography three months after transplantation of an 18 cm segment of jejunum in an animal shows the segment to be slightly dilated. About four months after transplantation, laparotomy was performed. The segment appeared normal on gross inspection. Later it underwent chronic rejection in spite of immunosuppressive therapy, finally causing death of the animal 205 days after the transplant was established. We performed transplants in several hundred animals in an attempt to prolong graft survival by various immunosuppressive programs. In one set of experiments animals were treated with azathioprine and prednisone

*Burnett

et al: Amer J Digest Dis 7: 833, 1962. The

American

Journal

of

Surgery

Intestinal

using a medium dose range. With either increase or decrease of the dose of the immunosuppressive drugs, graft survival was shorter. In other experiments allografts were placed in the recipient animal’s neck. Immunosuppression consisted of azathioprine, prednisone, and a variety of other agents, alone or in combination, including antilymphocytic serum and globulin prepared in either horses or rabbits. None of these regimens gave longer graft survival than azathioprine and prednisone in the medium dose range. One unsettled question is whether or not intestinal allografts function as digestive organs. A comparison of the enzyme contents in mucosal biopsies shows digestive enzymes in segments of allografts that were biopsied four to twelve days after transplantation. The dog’s jejunal epithelium “turns over” about every fortyeight hours, so these enzymes do not represent enzymes that were present before the segm,ents were transplanted. We can say from this that enzyme production by intestinal epithelium is preserved after transplantation, although the total amount of enzymes in the mucosa is less than in normal mucosa. These results have been reported previously.* In another experiment in which a dilute solution of glucose was put into a Thiry fistula 100 per cent of the glucose introduced into the fistula was absorbed. After the fistula was transplanted as an allograft there continued to be 100 per cent absorption. The blood glucose level in these animals was kept higher than the concentration of glucose in the fistula. Thus, jejunal allografts are able to absorb glucose against a concentration gradient. Later, when graft rejection begins, this function diminishes and finally ceases. RALPH DETERLING (Boston, Mass) : We faced this problem at the Boston Floating Hospital about six years ago in two patients: one infant and one young child who had total loss of the small intestine from mesenteric thrombosis. In the first instance, a segment of the mother’s ileum was used, but the child’s condition was so poor that in about twelve hours the child died of medical conditions. At that time the transplant appeared to be in fine condition and did not show any signs of rejection. The vasculature was open. The transplantation of the vessels was into the aorta and vena cava. The second child was of about the same size as the donor, who had been chronically ill of a fatal disease. It was possible to coordinate the operating time with the death of the donor. This was not successful for more than a couple of days, and after deterioration of the transplant, it was removed. The patient died a few weeks later. Unfortunately, there had been a cer* Preston

Volume

121,

et al: J Cardiovasc

February

1971

Surg,

September,

1970.

Transplantation

tain amount of antemortem autolysis and breakdown of the intestine in the donor before the time of transplantation. Different organs have varying rates of deterioration after death, a fact that must be taken into consideration in particular with the intestine. Physicians must exert maximal effort in order to obtain as good a transplant as possible. JAMES D. HARDY (closing) : We certainly have been aware of Dr Preston’s outstanding work, as well as of the fact that Dr Deterling had performed such a bowel transplantation. We are also well aware of Olivier’s work in Paris in this connection. There are one or two things I might comment on. In the first place, Lillehei, in transplanting the duodenum with the pancreas, has shown that actually the gut does do rather well in the allograft situation. We believed that this child had no other recourse but to undergo transplantation. Nevertheless, we brought the matter before the Committee on Human Investigation, and it was discussed at some length, especially the matter of using the mother’s bowel, which actually was a Terasaki class B match. It was unanimously agreed that the operation was justified under the circumstances. We should have anticipated that we might have trouble with the veins. The child had had swelling of the left leg, and that should have indicated that there must be thrombosis, at least on that side. The outcome was that the whole vena cava was thrombosed, which forced reconsideration of the site of implantation. Many of you are undoubtedly wondering why the graft was loose from the donor before everything was ready in the recipient? Actually, it was the difficulty met in sewing the very small gut artery to the aorta which prolonged the gut ischemia time. Nonetheless, the graft seemed well perfused at the end of the operation, and it was still viable a week later at exploration for what proved to be a perforated ulcer. At that time, much as one does with a kidney transplant, being uncertain of the future of the transplant, we decided to remove it and save the patient rather than run the risk of having the graft deteriorate further. The whole field of transplantation, especially that of gut transplantation, offers vast possibilities for modest attempts, but we do align ourselves with those who are trying to move the field forward. Many patients die of intestinal insufficiency in the United States each year. We have had three additional deaths from the same cause in the last few months, but all three patients had peritonitis, and therefore we accepted none of them for transplantation. Even so, this modality does represent a possibility for the future.

159