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小腸移植的現況與介紹
1. 蔡昕霖, MD, PhD, FACS
臺北榮總
Department of Surgery,
Taipei Veterans General Hospital
2. Part of the digestive system, one of the largest
organ systems in the body
Moves food
Absorbs fluids, nutrients and minerals
Also an essential endocrine organ
produces hormones that influence hunger, satiety, and
electrolyte homeostasis.
Symptoms of intestinal failure include:
persistent diarrhea, dehydration, muscle wasting, poor
growth, frequent infections, weight loss, and fatigue,
eventually leading to death
3. Based on data of safety
and efficacy:
HPN, primary treatment
of IF
Recent advances in HPN
Lower rate and later
onset of complications
The number of
transplants/year
declined
• 15~20% of HPN patients
are potential candidate for
SBT
4. Inability of the GI-tract to maintain an adequate
nutritional status and a fluid/electrolyte balance
Pathophysiology of IF
Short bowel syndrome
Motility disorder
Extensive parenchymal disease
Intestinal fistula
Intestinal rehabilitation programs
Medical treatment
Non-transplant surgery
Home parenteral nutrition (HPN)
5. Alexis Carrel (1912, Nobel Prize winner) was the first one to perform
it in an animal model
his description of a method of performing vascular anastomosis
Lillehei et al reported
The first canine model, 1959
The first case of human bowel transplantation, 1967
Deterling in Boston in 1964 (unpublished data), the first human
intestinal transplant
Between 1970 to1980
Poor outcome
All patients died of technical complications, sepsis, or rejection
The most significant advance in the development of intestinal
transplantation was the introduction of TACROLIMUS (1990)
The Starzl group (1998)
55 children
Patient survival rates were 55%, Graft survival rates were 52%
6. High immunogenicity
Intestinal epithelium: large absorptive surface
expresses donor HLA and non-HLA antigens
Large number of white cells
High risk of infection
Large number of bacteria
7. • Intestinal failure + life-threatening
complications
• Failure of HPN
• IFALD: 5-year risk of death Relative Risk (RR)/
3.2
• CVC-related thrombosis/sepsis: RR/1.1-2.1
Underlying disease
Desmoid tumor: RR/7.1
High morbidity and very poor quality of life
8.
9.
10. The busiest programs: USA
North America: 76% of the world
activity
Asian centers perform 34% of
their transplants using live donor
grafts vs. 1% worldwide
Centers in South America and
Asia
more transplants in sicker patients
(63% vs. 79% of patients were called
from home; p<0.001)
fewer grafts with liver component
(14% vs. 58%; p<0.001)
11. Small intestine transplant: intestine without the
liver or stomach;
Liver and small intestine transplant: intestine
with the liver but no stomach;
Modified multivisceral transplant: stomach and
intestine without a liver graft;
Multivisceral transplant: intestine plus liver and
stomach
The pancreas is included in the composite graft usually for
technical reasons and less frequently for medical indications
16. Improvements
Improved patient
management
Advances in surgical
technique
Immunosuppression
Graft surveillance
For patients transplanted at centres of excellence the actuarial overall patient
survival rate now is 93% at 1 year, 70% at 5 years and 50% at 10 years
17. History and physical (including mother history,
prematurity, previous surgeries)
Psychosocial evaluation
Laboratory analysis
Radiological studies
Tissue biopsy: liver, suspected lesion…etc
Cardiac and pulmonary status
Serology and tissue typing
18. Anesthetic induction and maintenance
Preenterectomy stage
Blood loss, core temperature
Enterectomy stage
Compromising venous return, toxin released from
abdominal infections
Neointestinal stage
Reperfusion effects, hypothermia
32. • Twice/week endoscopy in the first 4 weeks after
transplant, once weekly for 3 months, then
monthly
• Daily or every other day when rejection diagnosed
until resolution of clinical and histological signs
35. Indeterminate
Up to 6 apoptotic bodies per 10 crypts
Mild
>6 apoptotic bodies per 10 crypts
Moderate
Confluent apoptosis
Increased inflammation
Epithelial injury
Severe /Exfoliative
Features of moderate rejection plus mucosal ulceration
May have arteritis
Must be distinguished from CMV ulcers
Poor prognosis
45. • The leading cause of death and graft loss after SBT
• Nearly all patients (>95%) develop one or more
episodes of documented infections after transplant
• Average number of infection episodes: 5 per patient
• More common early after transplant: 50% 1-3 months,
25% 3-12 months, 25% > 12 months
• Causative agents:
– Bacterial
– Fungal
– Viral
– Many episodes of mixed infections (viral/bacterial
or bacterial/fungal)
48. 1. Infection with EBV
2. Seronegativity for EBV at the time of transplant
(post-transplant EBV infection)
3. Type of transplanted organ
• Intestinal transplant (28%), Heart/lung (10%), Liver
(2.2%)
4. Strength and length of immunosuppression
T-cell depletion agents (ATG, OKT-3), higher risk
High targeted level of tacrolimus, higher risk
5. Associated with CMV infection episodes
54. From IF to SBT: careful decision on a case-by
case basis
Current graft survival rates are comparable with
the results of other solid organ transplants
How to manage the complications, i.e. rejection,
infection, and PTLD is the challenge
