Intestinal Transplants Suitable Option in Severe Crohn's Disease

By James E Barone MD

September 04, 2014

NEW YORK (Reuters Health) - Intestinal transplantation is an acceptable alternative for patients with intestinal failure after Crohn's disease, according to a new study.

The report, online August 27 in JAMA Surgery, also proposes a new scoring system to help identify patients who might undergo this treatment instead of additional attempts at conventional surgery.

"This paper is the first to address a risk-benefit of transplantation vs. conventional therapy in Crohn's disease and also aims to create a scaffold for a referring physician to quantify the risk of morbidity from transplantation versus conventional therapy," senior author Dr. Anil Vaidya from Churchill Hospital in Oxford, UK, told Reuters Health by email.

Dr. Vaidya and colleagues reviewed the medical records of 20 patients referred for intestinal transplantation at two centers, one in Oxford and one in Berlin, between 2003 and 2013.

Based on the American Gastroenterology Association guidelines for intestinal transplantation, they developed a scoring system specific for Crohn's disease.

The team assigned points for various complications of the disease and patient performance status, and determined cutoffs for consideration of transplantation, definite indications for transplantation and transplantation not indicated due to unlikely survival benefit.

The patients had a number of important complications such as stomas or enterocutaneous fistulas (17 patients), life-threatening catheter infections (16), secondary organ failure (13 patients) and poor skin quality (20 patients).

Among those who had surgery, three had isolated intestinal transplants, three had intestinal plus abdominal wall transplants and four had multivisceral transplants.

The 10 patients who did not undergo surgery included four who declined the procedure and were lost to follow-up, four who were placed on a waiting list, one who had a stricturoplasty, and one who became too sick to undergo the surgery.

The two centers used different immunosuppressive regimens, but both were based on tacrolimus, the researchers note. The Oxford group used primary abdominal wall closure, and patients in Berlin underwent staged closures with allofascia and absorbable mesh or free flaps of latissimus dorsi muscle.

All patients were retrospectively classified with the new scoring system, and those who were transplanted had an average score of 18,400 -- well above the definite-transplant threshold of 5,000, but below the score of 25,000-30,000 at which a transplant was no longer considered an option.

The scoring system performed well when applied retrospectively to the patients who did not warrant transplantation.

"Patients with a score of less than 2000 continued to do well on home parenteral nutrition during the follow-up period, and patients with a score of more than 25000, deemed unsuitable for transplantation, succumbed to their disease process within the follow-up period," Dr. Vaidya said.

Within the first year, three transplanted patients developed acute cellular rejection, one to the abdominal wall only and two to the intestinal grafts. All were successfully treated with antirejection therapy.

Patients were followed for a mean of 27.6 months after surgery, with eight still alive and requiring no parenteral nutrition. The two deaths occurred within the first year from sepsis secondary to iatrogenic bowel perforations.

Performance status as assessed by Karnofsky scores improved in the operated patients from 55.6% when first seen to 74.4% after transplantation (p<0.001).

"The 20% mortality in patients undergoing transplantation indicates that transplantation is indicated only when there is a significant risk of death without transplantation," notes Dr. J. Michael Mills, a transplant surgeon at the University of Chicago, in a linked commentary in the journal.

Dr. Vaidya said he believes that if the patients who died had been referred earlier with lower scores they might have been able to better survive in the post-operative period.

He compared the current state of intestinal transplantation to that of the early days of both kidney and liver transplantation. "Look where we have come in a short span of 3 decades where pre-emptive renal transplantation has become the mainstay of renal replacement therapy," he said.

SOURCE: http://bit.ly/1nQltF5 and http://bit.ly/1tpeLgg

JAMA Surg 2014.

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