Sections

Intestinal and Multivisceral Transplantation

Sections Intestinal and Multivisceral Transplantation
Overview
Workup
Treatment
Guidelines
Media Gallery
Tables
References

Workup

Laboratory Studies

Perform a complete blood cell count to rule out anemia and thrombocytopenia. Assess electrolyte levels to look for electrolyte imbalance caused by short bowel syndrome. Perform the following liver function tests to rule out cholestatic liver failure and evaluate liver function:

Serum aspartate aminotransferase (AST)
Serum alanine aminotransferase (ALT)
Alkaline phosphatase (ALP)
Glucose tolerance test

Measure prothrombin time (PT) and activated partial thromboplastin time (aPTT) to rule out coagulation abnormalities and evaluate liver function. Measure the following to rule out deficiencies as the cause of thrombosis:

Protein C
Protein S
Clotting factors
Vitamins B12, K, and D

Perform urinalysis to evaluate renal function and rule out infection. Calculate creatinine clearance to evaluate renal function. Perform a culture to rule out infection. Assess vitamin levels to evaluate nutrition. Perform an absorption test to evaluate intestinal function.

Donor-specific antibodies (DSA) are evaluated to quantify the sensitization.

Citrulline levels are measured to monitor the condition of the intestine.

Additional tests that may be helpful include the following:

Total and direct bilirubin
Serum albumin
Phosphorus and magnesium
Cholesterol and triglycerides
Zinc and selenium
Free and total carnitine
Cytomegalovirus (CMV), Epstein-Barr virus (EBV), hepatitis B virus, hepatitis C virus, and human immunodeficiency virus
Alpha-fetoprotein
Cytotoxic antibody screen

Imaging Studies

Imaging studies include the following^[39]:

Doppler ultrasonography of the extremities to assess the patency of the veins
Doppler ultrasonography of the liver to assess the patency of the vessels
Computed tomography scanning of the abdomen
Upper gastrointestinal (GI) series with small bowel follow-through
Angiography of the abdomen
Magnetic resonance imaging/magnetic resonance angiography
Echocardiography/stress echocardiography
Nuclear medicine studies

Other Tests

Other tests that may be performed include the following:

Electrocardiography
Motility studies (as indicated)
Liver biopsy (as indicated)
Upper gastrointestinal endoscopy

If intestinal failure is functional, the diagnosis depends on the pathological findings and exclusion of other etiologies. Biopsy of the intestine is necessary for the final diagnosis. Perform case-by-case evaluations.

Treatment & Management

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Media Gallery

Anatomy of the donor operation, with procurement of the liver, small bowel, pancreas, and spleen en bloc (AO, thoracic aorta; HA, hepatic artery; PV, portal vein; CBD, common bile duct; D1, first part of the duodenum; TI, terminal ileum).
Small bowel recipient operation (AOI, interposition graft of aorta; AOII, Carrel patch bearing celiac trunk and superior mesenteric artery; AOIII, aortic end oversewn below superior mesenteric artery take-off; SV, native splenic vein; P, pancreas, with duct and parenchymal edge oversewn; PB, proximal bowel anastomosis; DB, distal ileocolonic anastomosis; LS, diverting loop ileostomy).
Intestinal transplantation: Back table operation with mesenteric vessels held within the forceps and the donor intestine within preservation solution.
Intestinal graft within the abdominal cavity of the recipient at the time of revascularization.
Revascularized bowel prior to closure. In the lower right corner the anastomosis between the donor small bowel and recipient remnant colon can be seen.
Picture of the liver and small bowel allograft. The liver is to the left of the picture, and the spleen can be seen lying within the loops of the small bowel (spleen is removed later).
Removal of the native liver. Left behind is the cavity into which the liver and small bowel allograft will be placed.
Postrevascularization image of the liver and small bowel allograft.
The allograft, prior to closure, positioned within the recipient's abdomen. The wedge-shaped excision (biopsy site) seen on the donor organ was performed at organ procurement. These biopsies are selectively performed to review the suitability of organs in instances where issues of suitability are raised.
Survival figures 2007. Image courtesy of the Intestinal Transplantation Registry (ITR).
Parenteral-nutrition related cholestasis. (This is a reversible pathology at this point, in the absence of fibrosis.)
Intestinal transplants by year in the United States. Data source: Organ Procurement and Transplantation Network https://optn.transplant.hrsa.gov/data/view-data-reports/national-data/#
Intestinal Transplantation. A) Pretransplant diagnosis-children, B) Pretransplant diagnosis-adults
Survival by era
Survival (2004–2009) by graft type
Survival (2004–2009) by pretransplant status
Graft survival by the liver, included or not (1985–2009)

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Author

Richard K Gilroy, MD, FRACP Gastroenterologist, Intermountain Healthcare

Disclosure: Received salary from gilead, NPS pharmaceuticals, salix pharmaceuticals, AbbVie for speaking and teaching.

Coauthor(s)

Jean Frederick Botha, MBBCh Assistant Professor, Transplant Surgeon, Department of Surgery, University of Nebraska Medical Center

Disclosure: Nothing to disclose.

Debra L Sudan, MD Professor of Surgery, Chief, Abdominal Transplant Surgery, Vice Chair of Clinical Operations, Department of Surgery, Duke University School of Medicine

Debra L Sudan, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society of Transplant Surgeons, American Society of Transplantation, American Surgical Association, Association for Academic Surgery, Nebraska Medical Association, Society for Surgery of the Alimentary Tract, Society of University Surgeons, Association of Women Surgeons, Association of Women Surgeons, International Liver Transplantation Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Stuart M Greenstein, MD Professor of Surgery, Albert Einstein College of Medicine; Consulting Surgeon, Department of Surgery, Division of Transplantation, Montefiore Medical Center

Stuart M Greenstein, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Society of Transplant Surgeons, American Society of Transplantation, Association for Academic Surgery, International College of Surgeons, Medical Society of New Jersey, National Kidney Foundation, New York Academy of Sciences, Southeastern Surgical Congress

Disclosure: Nothing to disclose.

Acknowledgements

Sandeep Mukherjee, MB, BCh, MPH, FRCPC Associate Professor, Department of Internal Medicine, Section of Gastroenterology and Hepatology, University of Nebraska Medical Center; Consulting Staff, Section of Gastroenterology and Hepatology, Veteran Affairs Medical Center

Sandeep Mukherjee, MB, BCh, MPH, FRCPC is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Merck Honoraria Speaking and teaching; Ikaria Pharmaceuticals Honoraria Board membership

Acknowledgments

The authors wish to thank Dr. Wendy Grant, Assistant Professor of Surgery, Section of Transplantation, University of Nebraska Medical Center, for providing the multimedia images in this article and the Intestinal Transplantation Registry (ITR) for providing the charts in this article.

Sections Intestinal and Multivisceral Transplantation
Overview
Workup
Treatment
Guidelines
Media Gallery
Tables
References

Medication	Days 2-29	Days 30-89	Days 90-179	Days 180-365	After 1 year
Tacrolimus (monotherapy levels)	15-20 ng/mL	12-15 ng/mL	10-12 ng/mL	7-10 ng/mL	Taper to around 5 ng/mL
Tacrolimus (in combination levels)	10-15 ng/mL	8-12 ng/mL	8-10 ng/mL	5-8 ng/mL	2.5-5 ng/mL
Prednisone (dose)	20 mg	15 mg	10 mg	7.5 mg	5 mg
Rapamycin (to be used only in combination with tacrolimus)	6-10 ng/mL	5-8 ng/mL	5-8 ng/mL	5-8 ng/mL	5-8 ng/mL
Mycophenolic acid (suggested dose as listed and to be used only in combination with tacrolimus; dose listed is adult dose; intolerance may be managed by lowering dose)	1000 mg bid	1000 mg bid	Cease unless renal indication exists	...	...

Intestinal and Multivisceral Transplantation Workup

Laboratory Studies

Imaging Studies

Other Tests

References

Tables

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