EditorialIntestinal Transplantation for Short Bowel Syndrome and Gastrointestinal Failure: Current Consensus, Rewarding Outcomes, and Practical Guidelines
Section snippets
World Experience
The 2003 report of the Intestinal Transplant Registry (ITR) that was addressed during the workshop and has been recently published highlighted a new era of intestinal transplantation with increased practicality and improved survival outcome.3 The data confirmed the therapeutic efficacy of the procedure for the intestinal failure patients who no longer can be maintained on total parenteral nutrition (TPN). The survival analysis of 923 patients that received 989 intestinal transplantations in 19
Current Indications
Intestinal transplantation has been primarily used only as a life-saving therapy for patients who failed TPN therapy and those with life-threatening abdominal pathology. Such limited indications were implemented during the early developing phase of the procedure and continued to be the guidelines for clinical practice by most transplant centers as well as health care providers, particularly CMS.2 In the 2001 CMS memorandum, failure of TPN therapy was defined by significant liver injury with
Type of Transplantation
There are 3 main different kinds of intestinal transplantation: intestine alone (Figure 4A), liver plus intestine (Figure 4B), and multivisceral that contains stomach, duodenum, pancreas, intestine, and liver (Figure 4C). According to the ITR data, the need for the intestine alone was more frequent in adults (55%) compared to children (37%), with more simultaneous hepatic replacement in children (50% vs 21%). Multivisceral grafts were given to more adults (24%) than children (13%). These
Evolution of Care and Current Guidelines
The postoperative management of intestinal recipients has steadily improved over the last 15 years with significant impact on survival, quality of life, and cost-effectiveness. However, a cohesive consensus on common practical guidelines among the currently active major intestinal transplant centers has yet to be established. Because of the limited publications and lack of controlled studies, Dr Horslen used the tool of personal communication to describe the up-to-date management protocols
Quality of Life and Cost-Effectiveness
With the continuous improvement in survival, quality of life and cost-effectiveness have become primary rather than secondary endpoints. With very limited scientific publications, Dr Sudan addressed these 2 important topics in a very comprehensive review.18 It is important to remember that these data are extrapolated from patients who received the intestinal transplantation as life saving in the absence of any alternative therapy.
The use of intestinal transplantation alone can be examined on a
Guidelines for Gastroenterologists
The clinical availability of intestinal transplantation and the recent significant improvement in survival has yet to be fully recognized by most gastroenterologists across the country and worldwide. As shown in Figure 5, and despite the use of the procedure as a rescue therapy for TPN failure, the survival outcome with intestinal transplantation is favorably comparable to the survival of home parenteral nutrition (HPN) patients with different disease categories.22 Such awareness of this new
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2019, Gastroenterology Clinics of North AmericaCitation Excerpt :The latest intestinal transplant registry reveals 1-, 5-, and 10-year graft survival rates to be 71%, 50%, and 40% and the patient survival rates to be 77%, 58%, and 47%, respectively.9 Despite the improved results of intestinal early transplantation currently in terms of comparable survival compared with home parenteral nutrition–dependent IF, a better QOL, and improved value of health care,10–14 early transplantation has yet to become a standard of care. Intestinal transplantation is reserved for patients with life-threatening complications of PN or underlying gastrointestinal disease.15