2. INTRODUCTION
intestinal transplatation has become a life saving treatment option for
intestinal failure.
The term intestinal failure encompasses multiple disorders of inadequate
intestinal length or function,that prevent adequate nutrient absorption.
Loss of nutrient absorption due to inadqute bowel length is called short
bowel syndrome.
Other conditions with loss of function but have normal bowel length are
Crohns diseses, motility disorders like intestinla psudo obstruction,hirsprungs
disease or loss of enterocyte function like intestinal epithelial hyperplasia.
3. HISTORY
Research was started earlier in1905 but most of
them were failure due to rejection.
Introduction of TPN has limited the need for
transplantation and research was limited.
Later due to development of complications of TPN
has again made need for transplatation research.
4. INDICATIONS FOR TRANSPALANTATION.
• Irreversible intestinal failure along following conditions
• Impending liver failure due to PNALD.
• Multiple thrombosis of central veins limiting the acess.
• More than two episode of catheter related infection causing hospital admissions.
• Single episode of central line fungl infection.
• Frequent and severe dehydration despite of IV fluid supplementation and TPN.
6. RECEPIENT EVALUATION
• Laboratory investigations: LFT’S,RFT’S, CBP,PTT-INR,APTT,PLATELET COUNT,ALBUMIN.
• Sereological tests: CMV,EBV,HBV,HCV AND HIV.
• Endoscopy: upper GI endoscopy, colonoscopy with biopsy.
• Pathology:percutaneous liver biopsy.
• Radiogrphy: upper GI series,small bowel follow through,barium enema,CT abdomen
and pelvis.
• Doppler USG of jugular vein and subclavian vein.
• Gastric emptying studies and motility studies.
7. DONOR EVALUATION
Most commonly cadveric donor organs are used.
Blood group typing compatabilty and size of the donor are
main criteria.
Donor should be atleast 50%-75% of recepint weight.
Cold ischemia time should be less.
If it prolongs there is a chance of loss of mucosal integrity and
translocation of bacteria may occur which leads to early
transplant perforations.
8. • Bowel is more senstive to injury typically
donor should be haemodynamically table and
geographically close to recepient tranplant
centre.
• Serological negative for CMV,EBV,HBV,HCV and
HIV.
9. TECHNICAL CONSIDERATIONS
• Isolated allograft typivcally include jejunum, ileum along with SMA
and SMV.
• Jejunum is transected distal ligament of trietz and ileum is
transected proximal ileocaecal valve.
• Level of SMA and SMV can be above or bellow the levelof
pancreas.
• If below they can be done at the root of mesentry.
• If above they ligated close to aorta and portal vein.
10. in recepient arterial anastomosis followed by venous
anastomosis followed by jejunum and ilostomy stoma.
Arterial conduits may be used for arterial anastomosis.
SMA is anastomose with aorta infra renal region.
SMV is anastomosed either to IVC or prtal vein.
11. INTESTINAL ALLOGRAFT ALONG WITH OTHER
ABDOMINAL ORGANS
• Mostly commonly done along with liver.
• Usually procedur is like indivdual transpaltation.
• Roux-en-y loop is created to maintain biliary
drainage.
• Enbloc transpalntation of
liver,duodenum,pancreas and small bowel was
done to maintain enterohepatic biliary circulaltion
12. IMMUNO SUPRESSION THERAPHY
• Introduction of cyclosporin has revolutionized the success of
bowel transplantation.
• Later tacrolimus [FK-506] is now used as maintainace
theraphy.
• Most of the centers recently use induction
immunosuppression theraphy intra operatively with
monoclonal antibody agent , and also ployclonal antibody
agents with satisfactory success rates.
• Steroid can also be used.
13. COMPLICATIONS
• Technical complications: anastmotic leaks are
most common,intestinal perforationsand
wound infection.
• Vascular complications are relatively rare
14. Monitoring and rejection:
Iloscopy scopy should be along with biopsy.
Should be started 5-7 post operatively follwed weekly once up to 3rd
month.
Maintainace of mucosal intergrity is and indiaction graft acceptance.
Loss of crypts and mucosal ulceration is and indication of graft
rejection.
Should be statedon steroid and itensive immuno suppresive
theraphy.
15. INFECTIONS
• Bacterial infections are most cause of sepsis
and death in this patients.
• Most common organisms include E.COLI,
KLEBSIELLA.
16. CMV INFECTION
Incidence ranges from 18-25%.
Varies from simple gastritis to graft rejection.
CMV bodies appear on microscopy patient should
be immediately started on IV ganicyclovir and CMV
immunoglobulins alond with intensifying the
immunosupresive theraphy.
17. EBV INFECTION
Incidence is 10-20% but relatively high when
compared with liver and kidney tranpalnts.
Simple fever with lymphadenopathy to life
threatening solid malignacies.reduction of immune
suppresive threaphy is first line of treatment with or
without anti viral treatment.
50-60% mortality rate was observed .
18. FINAL OUT COME
• one year survival rate was 70%
• Five year survival rate was50%
• Most common cause of death is
sepsis,rejection,cvs failure and PTLD.
