The current status of small bowel transplantation: The experience at the University of Miami

Intestinal transplantation is indicated in patients with end-stage intestinal failure and severe life-threatening complications of total parenteral nutrition or their disease. This is a retrospective study reviewing our experience with intestinal and multivisceral transplantation under immunosuppression with Tacrolimus and additional bone marrow-cell infusions at the University of Miami. Between August 1994 and October 1997, 42 intestinal transplantations were performed at our center, in 39 patients, 23 children and 16 adults. The main indications were short bowel syndrome due mainly to congenital diseases (gastroschisis, n=3, microcystic microcolon, n=3, intestinal artresia, n=2, etc.) in pediatric cases and acquired diseases (Crohn's disease, n=4, Gardner's syndrome, splanchnic vascular thrombosis, n=3, trauma, n=2, etc.) in adult cases. Severe complications as depleted venous access and liver failure always coexisted. Eight patients received isolated intestinal, 15 patients combined liver and intestinal and 16 patients multi visceral grafts. Bone marrow cells obtained from the same donor were administered into all but 12 cases for tolerance induction. Immunosuppression was based on Tacrolimus, low-dose steroids and more recently mycophenolate mofetil. Twenty-one patients are currently alive posttransplant, 19 patients bear their primary allografts and none of them require parenteral nutrition. Severe rejection and the consequences of its treatment were the cause of death in 11 patients and sepsis was the cause of death in 2 patients; other causes of death were arterial disruption probably due to pseudoaneurysm formation (aortoenteric fistula, n=1, aortic disruption, n=1), infectious complications (aspergillosis, n= 1, graft pancreatitis, n = 1, lung infection (adenovirus, n = 1, aspiration pneumonia, n = 1), viral encephalitis (n = 1), and a posttransplant lymphoproliferative disease (PTLD) in a pediatric case. Graft-versus-host disease was encountered in 8 patients and was treated successfully with corticosteroids. Although survival is lower than that of other solid organs, intestinal transplantation help salvage patients with an acceptable quality of life, who until recently would have no options.