Intestinal transplantation has evolved from an experimental procedure with limited success to standard of care for patients with intestinal and parenteral nutrition failure, achieving outcomes commensurate with other solid-organ transplants (Grant et al. 2005; Fishbein 2009). Paramount to achieving the success of intestinal and multivisceral organ transplant procedures has been the refinement of donor organ procurement and transplantation techniques (Fishbein et al. 2003a). Early graft failures and deaths due to technical and donor-related complications have been minimized using the techniques described here, leaving the current challenge largely of optimizing immunologic and infection management strategies (Fishbein 2004; Fishbein and Matsumoto 2005). The techniques depicted here are those of choice in our experience, though mention is made of alternative techniques that others may prefer (Abu-Elmagd et al. 2000; Fishbein et al. 2003b; Reyes et al. 1998; Tzakis et al. 1993). Because patients requiring intestinal transplantation often present with multiple organ failure and require multiorgan transplantation, modification of these techniques may be required to meet the needs of an individual patient. Some of the modifications that we have encountered include the addition of renal allotransplantation, inclusion of the colon in a small-bowel or multivisceral graft, and modified multivisceral transplantation with preservation of the native liver. Intimate description of all possible technical variations that might be required is beyond the scope of this chapter, and intestinal transplant surgeons should be prepared to draw from their experience in gastrointestinal and transplant surgery and employ generally accepted tenets as necessary.

Intestinal and Multivisceral Transplantation

Survival of patients identified as candidates for intestinal transplantation:a 3-year prospective follow-up

Short Bowel Syndrome in the Nicu

Long-Term Outcome of Chronic Intestinal Pseudo-Obstruction Adult Patients Requiring Home Parenteral Nutrition

Assessment and outcome of children with intestinal failure referred for intestinal transplantation.

We evaluated 131 patients (6 months–14 years) who experienced 21 deaths before listing, 11 continuing on the waiting list, 38 well on home parenteral nutrition, 6 off parenteral nutrition and 59 transplanted (20 girls) aged 2.5 to 15 years, (18 >7 years). They received cadaveric isolated intestine (ITx, n = 31) or liver-small bowel (LITx, n = 32), including right colon (n = 43; 23 LITx) for short bowel (n = 19), enteropathy (n = 20), Hirschsprung (n = 14), or pseudo-obstruction (n = 6). Treatment included tacrolimus, steroids, azathioprine, or interleukin-2 blockers. After 6 months to 10.5 years, the patient and graft survivals were 75% and 54%. Sixteen patients (10 LITx) died within 3 months from surgery (n = 3), bacterial (n = 5) or fungal (n = 6) sepsis, or posttransplant lymphoproliferative disorder (n = 2). Rejection occurred in 27 patients, including 10 steroid-resistant episodes requiring antilymphoglobulins. The grafts were removed due to uncontrolled rejection in seven ITx recipients. Surgical complications were observed in 38 recipients (25 LSBTx) within 2 months, including bacterial (n = 22) or fungal (n = 11) sepsis, cytomegalovirus disease (n = 12), adenovirus (n = 11), or posttransplant lymphoproliferative disorder (n = 12). Forty-two children (19 LSBTx) are alive. Weaning from parenteral nutrition was achieved after 42 days (median). Factors related to death or graft loss were pre-Tx surgery (P < .01), pseudo-obstruction (P < .01), age over 7 years (P < .03), fungal sepsis (P < .03), steroid resistant rejection (P < .05), hospitalized versus home patient (P < .01), and retransplantation (P < .05). Colon transplant did not affect the outcome. Interleukin-2 blockers improved isolated ITx (P < .05). Early referral and close monitoring of intestinal failure and related disorders are mandatory to achieve successful ITx.

Factors influencing outcome after intestinal transplantation in children

Pseudo purpura fulminans et primo-infection à HHV6

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Factors influencing outcome after intestinal transplantation in children

Pseudo purpura fulminans et primo-infection à HHV6