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7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
7 mangus intestinal transplantation
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7 mangus intestinal transplantation

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  • 1. Intestinal transplantation Dr. Richard S. Mangus, MD MS FACS Assistant Professor of Surgery Contact: rmangus@iupui.edu09/25/12 1
  • 2. Intestinal Failure Definition and Etiologies09/25/12 2
  • 3. Intestinal Failure - Definition• Failure of digestion and absorption• Inability of the intestinal tract to maintain adequate nutritional status and fluid / electrolyte balance• Results from a loss or absence of sufficient functional intestinal area09/25/12 3
  • 4. Intestinal Failure - Etiology Children • Short gut (necrotizing enterocolitis, others) • Intestinal atresia • Midgut volvulus • Gastroschisis • Hirschprung’s disease • Microvillus inclusion disease09/25/12 4
  • 5. Intestinal Failure - Etiology Adults • Short gut • Mesenteric thrombosis (arterial or venous) • Trauma • Inflammatory bowel disease / Crohn’s disease • Pseudo-obstruction • Tumors (desmoid, neuroendocrine tumors)09/25/12 5
  • 6. Intestinal Failure Management issues09/25/12 6
  • 7. Intestinal Failure - Management • Medically or surgically alter the remaining intestine to compensate for inadequate absorptive surface area • Meet caloric and nutritional requirements via an alternate route (parenteral nutrition (PN)) • Intestinal transplantation09/25/12 7
  • 8. Parenteral nutrition (PN) • First line therapy • Requires long term central venous access • Labor intensive • Expensive (total costs up to $1000/day) • Associated with serious and frequent complications – Infections – Loss of vascular access – Electrolyte abnormalities – Nutritional deficiencies (trace metals, other) – Liver disease09/25/12 8
  • 9. Parenteral nutrition – complications • Catheter related sepsis: – Standard site infection – Seeding from compromised intestine • Bacterial translocation • Avoiding catheter infections – Meticulous site care – 70% alcohol dwell – Antibiotic dwell09/25/12 9
  • 10. Parenteral nutrition – complications • Loss of vascular access – 6 primary sites for vascular access • Jugular, subclavian, femoral – Thrombus formation • May require anticoagulation • Heparin dwell – Vein sclerosis / narrowing09/25/12 10
  • 11. Parenteral nutrition – complications • Cholestatic liver disease – Progressive cholestasis and cirrhosis – Rate of progression may be associated with length of remaining intestine • Full intestinal length – liver failure slow onset • Short intestinal length – more rapid progression – Low lipid strategies • <1g/kg per day • Every other day or 3x/week lipids09/25/12 11
  • 12. Parenteral nutrition – complications • Cholestatic liver disease (continued) – Liver function tests in short gut patients are altered after 6 months in 15% to 40% of adults and 95% of children – Chronic cholestasis related to short gut, bacterial overgrowth, lipid infusion > 1g/kg, overfeeding , lack of oral feedings, infections – Liver dysfunction is the ultimate cause of death in 30 to 40% of PN patients09/25/12 12
  • 13. Parenteral nutrition – FAILURE • Medicare approved criteria for PN failure: – Impending/overt liver failure due to PN-induced liver injury – Thrombosis of 2 or more central venous access sites – The development of 2 or more episodes of systemic sepsis secondary to line infection, in one year, that requires hospitalization indicates failure of PN therapy – A single episode of line-related fungemia, septic shock, and/or acute respiratory distress syndrome is considered an indicator of TPN failure – Frequent episodes of severe dehydration despite intravenous fluid supplementation in addition to TPN.09/25/12 13
  • 14. Intestinal Transplantion Transplant options09/25/12 14
  • 15. Intestinal transplantation • Advantages: – Replace normal intestinal anatomy, continuity – Patient able to eat and drink – Chance for definitive cure of disease – Able to stop PN • Remove central venous catheters – Decrease infection risk – Decrease risk of loss of vascular access • Reversal of liver injury09/25/12 15
  • 16. Intestinal transplantation • Disadvantages: – Risks of major surgery – Risk of rejection – Risks of life-long immunosuppression • Infections • Cancers • Renal failure • Graft versus host disease09/25/12 16
  • 17. Intestinal Transplantation - surgery • Intestinal transplant options: – Isolated intestinal transplant • Small intestine only – Modified multivisceral transplant • Small intestine + pancreas + stomach – Full multivisceral transplant • Small intestine + pancreas + stomach + liver – Can add in other organs, as indicated • +/- kidney09/25/12 17
  • 18. Intestinal Transplantation - surgery • Surgical considerations: – Organs to include – Composite or separate – Whole or reduced size – Arterial inflow – Venous outflow – Enteric connection09/25/12 18
  • 19. Intestinal Transplantation • Intestinal transplant : Recipient operation09/25/12 19
  • 20. Intestinal Transplantation • Isolated intestinal transplant – Indication: Intestinal failure in the absence of any other organ failure • Normal function of liver, stomach, pancreas09/25/12 20
  • 21. Intestinal Transplantation • Isolated intestinal transplant09/25/12 21
  • 22. Intestinal Transplantation • Isolated intestinal transplant09/25/12 22
  • 23. Intestinal Transplantation • Isolated intestinal transplant09/25/12 23
  • 24. Intestinal Transplantation • Modified multivisceral transplant – Indication: Intestinal failure in the absence of liver failure • Normal function of liver • Dysfunction of stomach, intestine, +/- pancreas09/25/12 24
  • 25. Intestinal Transplantation • Modified multivisceral transplant09/25/12 25
  • 26. Intestinal Transplantation • Modified multivisceral transplant09/25/12 26
  • 27. Intestinal Transplantation • Multivisceral transplant – Indication: Intestinal failure with liver failure • Dysfunction of liver and intestine • +/- dysfunction of stomach and pancreas09/25/12 27
  • 28. Intestinal Transplantation • Multivisceral transplant09/25/12 28
  • 29. Intestinal Transplantation• Multivisceral transplant: – Liver / intestine transplant (+/- pancreas)09/25/12 29
  • 30. Intestinal Transplantation • Multivisceral transplant09/25/12 30
  • 31. Intestinal Transplantation • Multivisceral transplant09/25/12 31
  • 32. Intestinal Transplantation • Multivisceral transplant09/25/12 32
  • 33. Intestinal Transplantation • Non-traditional indications: – Diffuse mesenteric thrombosis – Benign/ low grade malignant tumors involving the mesenteric root • Neuroendocrine tumors (carcinoid, insulinoma, others) • Desmoid tumors – Abdominal catastrophes / fistulas – Radiation enteritis – Trauma – Enteropathies / dysmotility disorders09/25/12 33
  • 34. Post-transplant care Complications09/25/12 34
  • 35. Intestinal Transplantation - Rejection • Rejection – Isolated and modified multivisceral (liver excluded) • 1-year risk of rejection 45-50% – Multivisceral (liver included) • 1-year risk of rejection 15% • Liver known to be protective against rejection09/25/12 35
  • 36. Intestinal Transplantation - Complications • Other complications – Graft versus host disease (GVHD) – Post transplant lymphoproliferative disorder (PTLD) – Disease recurrence • Pseudoobstruction – Obstruction – Chronic rejection – Narcotic addiction (chronic pain)09/25/12 36
  • 37. Post-transplant Outcomes09/25/12 37
  • 38. Intestinal Transplantation - Volume U.S. intestinal transplant volume for last decade200 180 160 140 120 100 80 60 40 20 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 201009/25/12 38
  • 39. Intestinal Transplantation - Volume • World Intestinal Transplant Registry (ITR) – Worldwide database of all intestinal transplants – Between 2005 and 2007, 28 centers wordwide reporting to the ITR performed 389 intestinal transplants on 377 patients • In U.S. (Year 2010): – 151 transplants (-16% from previous year) – 17 centers with at least one transplant – 6 centers with 10 or more transplants09/25/12 39
  • 40. Intestinal Transplantation - Outcomes • U.S. Adult intestinal transplant outcomes Patient Survival Age group 1-year 5-years 18 to 34 years 81% 70% 35 to 49 years 80% 63% 50 to 64 years 93% 38% 65+ years 100% N/A From the Organ Procurement and Transplant Network (U.S.), 2002-200709/25/12 40
  • 41. Intestinal Transplantation – Costs• Cost to maintain a patient on PN ranges from $75,000-$200,000 per year – Added costs of home nursing, support, equipment• PN related complications result in an average of 1 major hospitalization per year, and catheter related complications are common and costly• Intestinal transplantation has been shown to be a cost effective therapy and is superior to continued PN in appropriately selected patients• Costs for intestinal transplantion, including the initial hospitalization for the transplant range from $200,000-$500,000• There are frequent hospital readmissions post-transplant, but these admissions decrease markedly after the second year post-transplant• The cost-benefit of transplantation reaches parity with PN after 2-3 years post-transplant and is more cost-effective thereafter09/25/12 41

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