Introduction

The evolution of intestinal transplantation has spanned over 40 years; however, clinical success was only achieved in the last decade. Between 1964 and 1972, only 8 intestinal transplants were performed, with the longest survival being 6 months.[1] Recipients were treated with intensive conventional immunosuppression, including combinations of prednisone, azathioprine, and antilymphocyte globulin. The discouraging results of these first clinical trials were a consequence of technical complications, sepsis, and the inability of conventional immunosuppression to control rejection, which was attributed to the large quantity of lymphoid tissue and bacterial load of the intestine. Almost concomitantly, home parenteral nutrition to sustain life, despite the risk of catheter sepsis and a compromised quality of life, was introduced. Consequently, enthusiasm for further development in intestine transplantation declined.

The introduction of cyclosporine (CsA) in 1980 increased survival with kidney, liver, and heart transplantation; however, results with intestine transplantation met with limited success.[2] Nevertheless, extended survival was seen in a few patients and included a 3-year-old girl who received a multivisceral transplant (stomach, duodenum, pancreas, small bowel, colon and liver).[3] Immunosuppression included CsA, corticosteroids, recipient and graft irradiation, and OKT3. Posttransplantation lymphoproliferative disease (PTLD) secondary to intensive immunosuppression was the cause of death rather than severe rejection.

One-year survival has been reported following transplantation of a living-related segment of a donor intestine[4] and in a 41-year-old woman with short gut syndrome (SGS) secondary to superior mesenteric artery thrombosis.[5] In a series of 6 intestine transplant recipients treated with CsA, the mean survival rate was 25.7 months -- 2 patients surviving for 5.5 and 5 years.[6] The longest-surviving patient of this era has survived 9 years under immunosuppressive management with CsA and corticosteroids.[7] This child received an isolated small intestine graft in 1989 following total volvulus of the gut. Good graft function was maintained on corticosteroids and CsA until 1998, when she presented with viral gastroenteritis and mild rejection. Immunosuppression was subsequently changed to tacrolimus (TAC). This patient is currently alive and well.[8]

The introduction of TAC in 1990 improved actuarial graft and patient survival rates following all types of intestine transplantation.[9] The use of TAC as the primary immunosuppressant in small bowel transplantation as well as improved surgical techniques, the availability of an increased array of potent immunosuppressive medications, infection prophylaxis, and suitable patient selection have contributed to the reality of this procedure for a growing number of patients who are total parenteral nutrition (TPN)-dependent and have permanent intestinal failure.

The objectives of this chapter are to:

 

  • Describe the current status of intestine transplantation

  • List underlying diseases and conditions that may result in the need for intestine transplantation

  • Identify patient populations who may benefit from intestine transplantation

  • Outline key steps in the evaluation of patients for intestine transplantation

  • Summarize current recommendations for immunosuppression

  • List the most common postoperative complications of intestine transplantation

  • Discuss recent advances in treatment and management of intestine transplant recipients.

 

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