Status of Intestine Transplantation

The international experience of small bowel transplantation since 1985 has been compiled and analyzed through the International Intestinal Transplant Registry.[10] As of May 2001, the Registry reported that 55 intestine transplant programs have been established, with 696 intestine transplants performed in 656 patients.

Combined intestine-liver transplantation was the most common type performed (44%), followed by isolated intestine transplantation (42%) and multivisceral transplantation (15%). The most common indications in adults are ischemia (22%), Crohn's disease (13%), trauma (12%), and desmoid tumor (10%); and in pediatrics, gastroschisis (21%), volvulus (18%), and necrotizing enterocolitis (12%).

The number of intestine transplants has increased annually, but has plateaued at about 100 cases annually for the last 4 years. Sex distribution was 56% male and 44% female; over 60% of patients were pediatric cases. Maintenance immunosuppression with TAC was used in the majority of recipients (97%). Actuarial graft survival of the total international experience at 5 years posttransplantation for isolated small intestine is over 45%, for combined intestine-liver is 43%, and for multivisceral transplantation, nearly 30%. Full graft function is observed in nearly 80% of recipients. Sepsis (49%) remains the primary cause of death following intestine transplantation. Additional causes include rejection (10%), lymphoma (8%), technical complications (8%), and respiratory complications (7%).[11]

In comparison to the overall survival rates reported by the Intestinal Transplant Registry, higher graft and patient survival rates are seen at the more experienced programs. Within the last 2 years, 1-year graft and patient survival at more experienced centers have reached 60% to 70% and 65% to 80%, respectively.[11] Likewise, at 2 years, graft and patient survival are 45% to 65% and 45% to 70%, respectively. [11] In a series of 121 patients receiving 127 transplants at the University of Pittsburgh, actuarial patient survival was reported to be 72% at 1 year and 48% at 5 years.[12] One- and 5-year graft survival rates were 64% and 40%, respectively. From 1995 to 1999, a significant improvement in graft survival was seen in this series with graft survival of 65%, reflecting program modifications, management strategies, immunosuppressive protocols, and refinements in surgical techniques. In a follow-up of 55 pediatric patients who received 58 intestine transplants from 1990 to 1996 at the University of Pittsburgh, 30 patients were alive with an actuarial survival at 1, 3, and 5 years posttransplantation of 72%, 55%, and 55%, respectively.[13]

The impact of different immunosuppressive strategies, patient and graft monitoring, and improvements in surgical techniques was evaluated at the University of Miami in a series of 77 intestine transplants performed in 69 patients during 3 program phases: 1994-95, 1995-97, and 1997-99.[14] Two-year graft survival rates for isolated small intestine transplantation for phases 1, 2, and 3 were 0%, 50%, and 80%, respectively. Graft survival rates in combined liver-intestine and multivisceral groups at 2 years during the same phases were 40%, 30%, and 48%, respectively. It was suggested that improvements may have been the result of induction therapy with daclizumab and close surveillance protocols including ileoscopy and biopsy.

From 1990 to 1999, 32 isolated small intestine transplants and 49 combined small bowel-liver transplants were performed in 81 patients at the University of Nebraska.[15] Overall graft survival in the isolated small bowel group was 50%. From 1990 to 1993, 6 patients received combined small bowel-liver transplants. There is 1 long-term survivor at 7.5 years posttransplantation. From 1994 to 1999, 43 small bowel-liver transplants were performed with an overall patient survival rate of 60% (n = 26).

Improvements in small bowel transplantation have also resulted in decreased costs. Between 1990 and 1994, the average cost was $203,111 for an isolated intestine transplant, $252,453 for a combined liver-small bowel transplant, and $284,452 for a multivisceral transplant.[16] By 1999, the average costs had decreased appreciably and were $132,285 for an isolated intestine transplant, $214,716 for a combined liver-small bowel transplant, and $219,098 for a multivisceral transplant.

Significant progress has been made in small bowel transplantation over the past decade as it has advanced from an experimental strategy to a feasible alternative for those patients with permanent intestinal failure and complications associated with the underlying disease and/or TPN. Further refinements and improvements in immunosuppressive protocols, surgical techniques, infection management and prophylaxis, as well as early patient referral and appropriate patient selection are crucial to maximize outcomes.

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