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ABSTRACT
Introduction
Advances in the management of intestinal failure have led to a reduction in the number of intestinal transplants. The number of bowel transplants has been mainly stable even though a slight increase has been observed in the last 5 years.
Areas covered
Standard indication includes patients with a reasonable life expectancy. Recent progress can be deduced by the increased number of intestine transplants in adults: this is due to the continuous improvement of 1-year graft survival worldwide (without differences in 3- and 5-year) associated with better abdominal wall closure techniques. This review aims to provide an update on new indications and changes in trends of pediatric and adult intestine transplantation. This analysis, which stretches through the past 5 years, is based on a collection of related manuscripts from PubMed.
Expert commentary
Intestinal transplants should be solely intended for a group of individuals for whom indications for transplantation are clear and both medical and surgical rehabilitations have failed. Nevertheless, many protocols developed over the years have not yet solved the key question represented by the over-immunosuppression. Novel indications and recent progress in the bowel transplant field, minimal yet consistent, represent a pathway to be followed.
Article highlights
Intestinal transplantation should be strictly reserved to a group of individuals for whom the indications to transplant are clear and medical and surgical rehabilitations have failed.
Medical approaches (such as rehabilitation or in the near future proteomic therapy) and non-transplant surgical techniques have a central role in the management of patients with intestinal failure.
Novel criteria for intestinal transplant are recently emerged implementing new indications to transplant apart from the standard ones.
Quality of life itself does not represent an option for transplantation unless other indications are present.
The intestine is the most immunologically complex solid organ allograft with the greatest risk of both rejection and graft-versus-host disease: high levels of immunosuppression are required, increasing morbidity and mortality.
Tacrolimus-based regimens are the leading induction agents for immunosuppressive therapies.
Abbreviations
| IF | = | Intestinal failure |
| GI | = | Gastrointestinal |
| PN | = | Parenteral nutrition |
| SBS | = | Short bowel syndrome |
| IA | = | Intestinal adaptation |
| MSBR | = | Massive small bowel resection |
| HPN | = | Home parenteral nutrition |
| IFALD | = | Intestinal failure associated liver disease |
| ITx | = | Intestinal transplantation |
| SBL | = | Small bowel length |
| ICV | = | Ileocecal valve |
| QOL | = | Quality of life |
| GF | = | Growth factor |
| AGIR | = | Autologous gastrointestinal reconstruction |
| IRPs | = | Intestinal Rehabilitation Programs |
| LILT | = | Longitudinal intestinal lengthening and tailoring |
| STEP | = | Serial transverse enteroplasty |
| SILT | = | Spiral intestinal lengthening and tailoring |
| IRTA | = | Intestinal Rehabilitation and Transplant Association |
| ESPEN | = | European Society for Clinical Nutrition and Metabolism |
| CRBS | = | catheter-related bacteremia/sepsis |
| OPTN | = | Organ Procurement and Transplantation Network |
| AMS | = | Antibody-mediated rejection |
| DSAs | = | Donor-specific antibodies |
| IS | = | Immunosuppression |
| ACR | = | Acute cellular rejection |
| HLA | = | Human leukocyte antigen |
| IVIG | = | Intravenous immunoglobulin |
| GVHD | = | Graft-versus-host disease |
| mTOR | = | Mammalian target of rapamycin |
| E&B | = | Endoscopy and biopsy |
| PTLD | = | Post-transplant lymphoproliferative disease |
| MvTX | = | Multi-visceral transplantation |
| MMvTX | = | Modified multivisceral transplantation |
| CLABSI | = | Central line – associated bloodstream infection |
Acknowledgments
We wish to thank Ms Elena BALDISSONE for her invaluable support in English editing.
Declaration of interest
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
Reviewer disclosures
Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.