Pediatric intestinal transplantation: Historical notes, principles and controversies

Abstract

The development in technique and immunosuppressive management of the last 12 yr have made intestinal transplantation an effective treatment for children with intestinal failure. The information provided in this review support such a conclusion, but was more clearly validated by the March 2001 Medicare Report which provided a national coverage decision of the Social Security Act for intestinal transplantation. As of May 2001, there were 55 centers world-wide which have performed 696 intestinal transplants in 656 patients. (Intestinal Transplant Registry, http://www.lhsc.on.ca/itr) the majority of recipients have been children, and there has been a greater need for liver replacement in conjunction with the allograft intestine because of a higher incidence of TPN-induced cholestatic liver disease in children. Though overall long-term survival is approximately 50%, similar advances in surgical, clinical and immunosuppressive management since 1995 have improved patient survival to more than 70% in most experienced programs. Over 80% of survivors are enjoying nutrition-supporting intestinal function. The major causes of graft loss and patient demise continues to be rejection and infection. Tacrolimus remains the mainstay of immunosuppressive therapy. Further experience other induction protocols utilizing rapamycin and daclizumab, as well graft pretreatment protocols may further enhance results in the future.

Multivisceral and isolated intestinal procurement techniques

“…(Liver Transpl 2003;9:881-886. )I mproved outcomes after multivisceral and isolated intestinal transplantation [1][2][3][4][5][6] have renewed interest in these techniques as evidenced by United Network for Organ Sharing (UNOS) data showing annual increases in isolated intestinal and multivisceral transplantation since 1998. 7 In an era of limited cadaver-donor supply, enhanced recognition of potential multivisceral/intestinal cadaver-donors is necessary.…”

“…Donor selection is restricted to optimal candidates according to widely recognized criteria 6,13 including ABO compatibility, appropriate size-match, minimal vasopressor requirements, absent/scant arrest period, serum sodium Ͻ 160 mEq/dL. Preparation of the donor before procurement includes selective intestinal decontamination using neomycin, erythromycin, and amphotericin B, in addition to intravenous antibiotic prophylaxis with a third-generation cephalosporin at the time of surgery.…”

Successful Isolated Intestinal Transplantation in Sensitized Recipients With the Use of Virtual Crossmatching

“…However, the requirement for a liver inclu- sion graft is decreasing (2011 Intestine Registry Report, http://www.intestinetransplant.org), likely due to the improved management of intestine-failure associated liver disease (28,29). Concurrently, intestine transplant outcomes continue to improve and 1-year patient survival rates now exceed 90% at experienced high-volume intestinal transplant centers (15,23,30). With the growing success of intestinal transplantation, more patients will undergo this therapy, and the isolated intestine transplant will likely become the predominant procedure.…”

The First Intestinal-Multivisceral Transplant in Poland — A Case Report

“…It is suggested to use triple drug immunosuppressive therapy with tacrolimus, prednisolo- transplant lymphoproliferative disease (15-20% of recipients). During the last few years, survival after intestinal transplantation has been slowly but steadily improving and ranged about 50-60% at 5 years after transplantation (4,5,6).…”