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Intestinal & Multivisceral


                                              Intestinal & Multi-Visceral Transplantation: Version 7.0

The general topic of intestinal transplantation includes intestine, intestine with liver, and intestine with the liver, stomach and possibly pancreas. The latter is referred to as a multi-visceral transplant. Because there may be multiple anatomic and functional abnormalities associated with intestinal failure, depending on the underlying illness, previous surgery, and/or status of Total Parenteral Nutrition (TPN), the patient may require transplantation of the liver and/or stomach in addition to the small intestine. The most common types of small intestine transplants are small intestine alone (41%) and multi-visceral transplants (59%). In the remainder of this guide we will refer to all forms under the more generic term of intestinal transplant.

The incidence of intestinal transplantation in the United States is rare and actually declining. Intestinal transplantation peaked in the United States in 2007 when 197 patients received a small bowel transplant as either a solitary organ or part of a multivisceral operation. In 2014 only 139 patients underwent small bowel transplantation at 15 centers. As of December 2015 there were 264 patients awaiting small bowel transplantation.

The need for parenteral nutrition (hyperalimentation) is not in itself an indication for intestinal transplant. The indication is failure of parenteral nutrition. However, a fuller understanding of the definition of parenteral nutrition failure is necessary to understand candidacy for this challenging, expensive, and frequently unsuccessful operation. Medicare approved indications include parenteral nutritional failure defined as significant biochemical or histological evidence of liver injury. Loss of central venous access or recurrent episodes of line sepsis is another Medicare approved indication for small bowel transplantation as are recurrent episodes of severe and potentially life threatening dehydration despite intravenous fluids.

The most common conditions leading to Intestinal Transplantation are short bowel syndrome (either congenital or acquired), neoplasms, motility disorders, mucosal defects, and intestinal re-transplant (after a previous failed operation).

Historically, Intestinal Transplantation was more common in the pediatric population. This is no longer the situation with adult small bowel transplant being slightly more common than pediatric transplantation.

The question arises: why isn’t the transplant community more enthusiastic about this operation and why isn’t the volume of operations increasing. The answer, of course, is complicated. However, the simple explanation is that only 50% of the grafts survive 5 years, virtually all of the patients will require multiple re-hospitalizations, that immunological problems persists significantly longer than with other solid organ transplants, and the costs of a complicated transplant can be absolutely astronomical. However, there is also a bright side to this as we are focusing on better approaches to Intestinal Rehabilitation.

Non-transplant intestinal rehabilitation techniques include:
        A. Diet Modification
        B. Fiber Supplementation
        C. Oral Rehydration Solutions
        D. Specialized nutrients (e.g. glutamine)
        E. Medications
        F. Enteral Nutrition
        G. Tropic factors (e.g. growth hormone)
        H. Reconstruction surgery
        I. Lengthening procedures

Surgical approaches can significantly increase the absorptive surface and potentially resolve the need for parenteral nutrition in patients with short bowel syndromes. Long-term hyperalimentation is both a blessing and a curse for many of these patients. It is life sustaining when a patient cannot maintain themselves orally, but it almost inevitably results in significant liver injury. That is why intestinal transplantation was historically a combined liver and intestinal transplant. We now have and are continuing to evolve better long-term approaches to hyperalimentation to minimize hepatic injury.  We have also learned that intervening earlier with intestinal transplantation, in appropriate cases that do not respond to attempts at rehabilitation, allows successful outcomes with isolated intestinal transplant.

Intestine Transplant 2015

 

All Ages

< 1Y

1-5 Y

6-10Y

11-17Y

18-34Y

35-49Y

50-64Y

65+

Liver-Intestine

2

0

0

1

0

0

0

1

0

Liver-Kidney-Pancreas-Intestine

2

0

0

0

0

0

1

0

1

Pancreas-Intestine

9

0

0

0

1

3

4

1

0

Liver-Pancreas-Intestine

679

1

32

6

2

9

9

8

0

Kidney-Intestine

2

0

0

0

0

0

2

0

0

Liver-Kidney-Intestine

0

0

0

0

0

0

0

0

0

All Intestine

82

1

32

7

3

12

15

10

1


As of August 22, 2016 only 9 centers have been certified by Medicare (CMS) [1] for adult transplants and 12 centers for pediatric transplants:
 
    • University of Pittsburgh Medical Center (Pittsburgh, PA)
    • University of Nebraska (Omaha, NE) – Adult and Pediatric
    • Mt. Sinai Medical Center (New York City, NY)
    • Jackson Memorial Hospital (Miami, F – Adult and Pediatric
    • Ronald Regan UCLA Medical Center (Los Angeles, CA)
    • Indiana University Health, Inc. (Indianapolis, IN)
    • Georgetown University Hospital  (Washington, DC) – Adult and Pediatric
    • The Cleveland Clinic Foundation (Cleveland, OH)
    • New York Presbyterian Hospital (New York, NY) – Pediatric
    • Henry Ford Hospital (Detroit, MI)
    • Children’s Hospital of Pittsburgh(Pittsburgh, PA) – Pediatric
    • Children’s Hospital of Los Angeles (Los Angeles, CA) – Pediatric
    • Lucile Salter Packard Children’s Hospital (Palo Alto, CA) -Pediatric
    • Boston Children’s Hospital (Boston, MA) –Pediatric
    • Children’s Hospital Medical Center (Cincinnati, OH) – Pediatric
    • Children’s Medical Center Dallas (Dallas, TX) – Pediatric
    • Seattle Children’s Hospital (Seattle, WA) – Pediatric
    • Ann & Robert H. Lurie Children’s Hospital of Chicago (Chicago, IL) – Pediatric

INTERLINK Health Services Transplant Network credential standards require CMS certification for adult intestinal transplant programs at a minimum.

In general, patient survival in the major centers performing intestinal or multivisceral transplants is better than reported in the SRTR reports. Considerable advances have been made in recent years as the principal centers have acquired additional experience. The benefit of this experience is not fully expressed in the current data from SRTR as the measured cohorts include patients from prior years.

1 Centers for Medicare and Medicaid Services, Division of Technical Payment Policy, List
of Medicare Approved Intestinal Transplant Centers. August 22, 2016.