7 mangus intestinal transplantation
Transcript of 7 mangus intestinal transplantation
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Intestinal transplantation
Dr. Richard S. Mangus, MD MS FACSAssistant Professor of SurgeryContact: [email protected]
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Intestinal Failure
Definition and Etiologies
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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 area
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Intestinal Failure - Etiology
Children• Short gut (necrotizing enterocolitis, others)
• Intestinal atresia
• Midgut volvulus
• Gastroschisis
• Hirschprung’s disease
• Microvillus inclusion disease
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Intestinal Failure - Etiology
Adults• Short gut• Mesenteric thrombosis (arterial or venous)• Trauma• Inflammatory bowel disease / Crohn’s
disease• Pseudo-obstruction• Tumors (desmoid, neuroendocrine tumors)
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Intestinal Failure
Management issues
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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 transplantation
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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 disease
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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 dwell
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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 / narrowing
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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 lipids
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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 patients
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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.
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Intestinal Transplantion
Transplant options
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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 injury
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Intestinal transplantation
• Disadvantages:– Risks of major surgery– Risk of rejection– Risks of life-long immunosuppression
• Infections• Cancers• Renal failure• Graft versus host disease
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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
• +/- kidney
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Intestinal Transplantation - surgery
• Surgical considerations:– Organs to include– Composite or separate– Whole or reduced size– Arterial inflow– Venous outflow– Enteric connection
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Intestinal Transplantation
• Intestinal transplant : Recipient operation
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Intestinal Transplantation
• Isolated intestinal transplant– Indication: Intestinal failure in the absence of
any other organ failure• Normal function of liver, stomach, pancreas
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Intestinal Transplantation
• Isolated intestinal transplant
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Intestinal Transplantation
• Isolated intestinal transplant
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Intestinal Transplantation
• Isolated intestinal transplant
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Intestinal Transplantation• Modified multivisceral transplant
– Indication: Intestinal failure in the absence of liver failure• Normal function of liver• Dysfunction of stomach, intestine, +/- pancreas
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Intestinal Transplantation• Modified
multivisceral transplant
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Intestinal Transplantation
• Modified multivisceral transplant
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Intestinal Transplantation
• Multivisceral transplant– Indication: Intestinal failure with liver failure
• Dysfunction of liver and intestine• +/- dysfunction of stomach and pancreas
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Intestinal Transplantation
• Multivisceral transplant
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Intestinal Transplantation• Multivisceral transplant:
– Liver / intestine transplant (+/- pancreas)
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Intestinal Transplantation• Multivisceral
transplant
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Intestinal Transplantation• Multivisceral
transplant
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Intestinal Transplantation• Multivisceral
transplant
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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 disorders
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Post-transplant care
Complications
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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 rejection
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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)
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Post-transplant
Outcomes
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Intestinal Transplantation - Volume
020406080
100120140160180200
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
U.S. intestinal transplant volume for last decade
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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 transplants
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Intestinal Transplantation - Outcomes
• U.S. Adult intestinal transplant outcomes
Patient Survival
Age group 1-year 5-years18 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.), 2002-2007
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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 thereafter