Intestinal failure: a viable proposition in India

Abstract

Total parenteral nutrition (TPN) is currently the primary maintenance therapy for patients with irreversible gut failure. It is associated with significant morbidity and mortality and poor quality of life. Liver disease is the most common complication of TPN. Thrombosis at site of insertion, recurrent episodes of catheter related sepsis, dehydration, formation of renal calculi and electrolyte disorders are other common complications [1]. Small bowel transplantation has evolved as a successful therapeutic option in the treatment of irreversible gut failure.Cadaveric small bowel transplantation is associated with satisfactory outcomes at most centers. However, the high mortality rate among patients awaiting intestinal transplants exceeds that among candidates waiting for solid organ transplants in certain age groups especially children.Living donor intestinal transplant (LDIT) has emerged as a viable option in patients with intestinal failure. Use of living donors makes the transplant an elective procedure with minimal waiting and cold ischemia times and allows HLA matching. Further, the desire to help a suffering member of the family, particularly for parents donating to their sick child confers psychological benefit even though they do not undergo an operation to improve their own health [2]. Factors such as size match are not as crucial in LDIT as in cadaver transplant, where a donor that is 50 % to 75 % of the size of the recipient is usually preferred, owing to multiple prior laparotomies, adhesions and loss of abdominal wall in the recipient.LDIT can be performed as an elective operation when both the donor and recipient are in best possible health and after complete evaluation of the donor, unlike cadaveric transplants, which, by necessity, have to be performed as and when a graft becomes available. Again donor bowel preparation can easily be performed, reducing the risk of infectious complications.Though the significance of HLA matching in intestinal transplant is still to be determined, potential immunologic advantage can be obtained by using HLA matched grafts, even though experienced programs have attained low rate of rejection with poorly matched diseased intestinal grafts [3].By co-ordinating the donor and recipient operations and using parallel teams, the cold ischemia time (<5 h) can be minimized and the risk of risk of ischemic damage to the graft due to hemodynamic instability of the donor leading to splanchnic hypoperfusion is virtually eliminated. In their series of 26 cases of LDIT, Benedetti et al. reported a cold ischemia time of 5 min and warm ischemia time of 30 min [3].Two important goals of LDIT are donor safety and TPN independence. According to the technique standardized by Gruessner and Sharp [4], a graft of around 200 cm in adult recipients and 150 cm in pediatric recipients is sufficient to obtain TPN independence. This corresponds to approximately 40 % of the total bowel length in the donor. The length of the bowel left in the donor is very crucial. More importantly, at least 60 % o...