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• Authors' reply: Small intestinal transplantation
  Stephen J Middleton
  Published on: 18 April 2016
• Is this really the current status of small bowel transplantation in the UK?
  Girish L Gupte
  Published on: 18 April 2016

• Published on: 18 April 2016

  Authors' reply: Small intestinal transplantation

  • Stephen J Middleton, Gastroenterologist
  • Other Contributors:
    • Neville V Jamieson

  Dear Editor,

  Dr Gupte and colleagues conclude that our article "does not acknowledge the contribution of the paediatric experience in this developing field" Nonetheless, the article does outline the development of small intestinal transplantation internationally for both adults and paediatrics and includes all of the paediatric outcome data submitted to the international registry, which we believe does include t...

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  Dear Editor,

  Dr Gupte and colleagues conclude that our article "does not acknowledge the contribution of the paediatric experience in this developing field" Nonetheless, the article does outline the development of small intestinal transplantation internationally for both adults and paediatrics and includes all of the paediatric outcome data submitted to the international registry, which we believe does include the Birmingham cases. The mission of the article was to orientate the general reader as to the global situation and lay emphasis upon certain aspects of the UK provision which might be improved by their increased awareness, rather than enhance the knowledge of the transplant specialist. One of the specific local UK problems is the poor referral rate of adults in particular which may stem from an overly conservative approach to the management of sudden intestinal failure requiring salvage surgery and parenteral nutrition as well as late referral of adults to the intestinal failure centres. It was not the aim of the article to cover the details of the UK adult or paediatric transplantation centres' experiences which have been published elsewhere. We feel that the article largely satisfies its mission to inform the generalist and that inclusion of a detailed comprehensive description of aspects such as post operative infection, PTLD and the surgical reduction techniques commonly needed in paediatric practice would have steered away from our aim. We agree however that the type of information provided in Dr Gupte's letter is of great importance but more so to the specialists undertaking the procedure that to the non transplant specialist who might wish to refer a patient for consideration of intestinal transplantation.

  Yours sincerely,

  Dr S J Middleton, Gastroenterologist
  Mr N V Jamieson, Hepatobiliary and Transplant Surgeon

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  Conflict of Interest:
  None declared.

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• Published on: 18 April 2016

  Is this really the current status of small bowel transplantation in the UK?

  • Girish L Gupte, Consultant Paediatric Hepatologist
  • Other Contributors:
    • Sue V Beath, Alastair JW Millar, Deirdre A Kelly

  Dear Editor,

  We read with interest the article on ‘The current status of small bowel transplantation in the UK and internationally’ by Middleton et al.[1] This is a timely article about the improving worldwide outcome following small bowel transplantation, but does not fully reflect the status of small bowel transplantation in the UK. In the UK, the Department of Health through NSCAG (National Specialist Commissio...

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  Dear Editor,

  We read with interest the article on ‘The current status of small bowel transplantation in the UK and internationally’ by Middleton et al.[1] This is a timely article about the improving worldwide outcome following small bowel transplantation, but does not fully reflect the status of small bowel transplantation in the UK. In the UK, the Department of Health through NSCAG (National Specialist Commissioning Advisory Group) recognises and funds three units for small bowel transplantation [two adult centres- Addenbrooke’s Hospital, Cambridge; St James Hospital, Leeds; and single paediatric centre- Birmingham Children’s Hospital (BCH)] since 1997. The majority of transplants in the UK to date have been carried out in children, which also reflects the international situation. Thirty eight intestinal transplants have been performed in children at BCH since 1993 compared to 14 transplants in the adult population in the last 15 years at two adult centres.[1]

  The paediatric experience has taught us many useful lessons which also benefit adult recipients, such as : reduction of graft size[2], increased awareness about post-transplant infectious enteritis and Epstein Barr virus (EBV) related post-transplant lympho-proliferative disease (PTLD), which are risk factors for death following small bowel transplantation in both adults and children.[3,4]

  Since the introduction of graft reduction techniques, we have performed 21 en-bloc reduced combined liver and small bowel transplants thus extending the donor pool and facilitating transplantation of small children from older donors.[2]

  In a recent report from the UCLA group, infectious enteritis (IE) with viruses (adenovirus, EBV and rotavirus) and protozoa (Giardia Lamblia, Cryptosporidium) has been reported in 3 adults and 10 children following small bowel transplantation. This is an under-reported and under -diagnosed complication following intestinal transplantation. A high index of suspicion and prompt laboratory investigations are necessary to arrive at an early diagnosis as the clinical features can mimic acute cellular rejection (ACR) and the treatment of IE is very different to ACR.[3]

  Epstein Barr Virus (EBV) related post-transplant lymphoproliferative disease (PTLD) is seen more commonly in children who unlike adults are EBV seronegative pre-transplant, but also occurs in adults following small bowel transplantation.[4] The diagnosis of EBV related PTLD is based on high viral EBV PCR loads and histopathological examination. Treatment modalities such as reduction of immunesuppresssion , surgical resection for control of local complications, anti CD20 monoclonal antibody (Rituximab), adoptive immunotherapy, cytotxic chemotherapy are helpful in treatment of this invasive disease.[5] Awareness about PTLD and serial EBV PCR monitoring has reduced the incidence of PTLD in the last Decade.[4,5]

  In conclusion, this article does not acknowledge the contribution of paediatric experience in this developing field.

  Reference List

  1. Middleton SJ,.Jamieson NV. The current status of small bowel transplantation in the UK and internationally. Gut 2005;54:1650-7.

  2. de Ville dG, Mitchell A, Mayer AD, Beath SV, McKiernan PJ, Kelly DA et al. En block combined reduced-liver and small bowel transplants: from large donors to small children. Transplantation 2000;69:555-9.

  3. Ziring D, Tran R, Edelstein S, McDiarmid SV, Gajjar N, Cortina G et al. Infectious enteritis after intestinal transplantation: incidence, timing, and outcome. Transplantation 2005;79:702-9.

  4. Grant D, Abu-Elmagd K, Reyes J, Tzakis A, Langnas A, Fishbein T et al. 2003 report of the intestine transplant registry: a new era has dawned. Ann Surg 2005;241:607-13.

  5. Green M,.Webber S. Posttransplantation lymphoproliferative disorders. Pediatr Clin.North Am. 2003;50:1471-91.

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  Conflict of Interest:
  None declared.

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