Small Bowel Transplantation: the New Frontier in Organ Transplantation

  • Michel M. Murr
  • Michael G. Sarr
Chapter
Part of the Springer Specialist Surgery Series book series (SPECIALIST)

Abstract

The last ten years have witnessed the emergence of small bowel transplantation (SBT) as a viable treatment modality for selected patients with intestinal failure. The introduction of effective immunosuppressive medications was the most important factor in allowing transplantation of this “forbidden organ”. The technical aspects of harvesting and transplanting the intestine were studied early in the century by Alexis Carrel and later refined by Lillehei and colleagues [1] at the University of Minnesota in 1955. Monchick and Russell [2] established a rat model for SBT which opened the door for investigators to explore unidirectional immune phenomena as well as physiologic function of the transplanted gut. All seven attempts at SBT in humans that were made prior to the introduction of cyclosporine failed because grafts were lost to early rejection or sepsis. Experience with SBT under cyclosporine immunosuppression was encouraging, but ultimately proved to be unsatisfactory as graft loss to rejection continued to be inevitable. Success in human SBT hinged on the advent of FK506 (tacrolimus), which has shown to be of great promise in liver and experimental SBT.

Keywords

Fermentation Glutamine Folic Acid Leucine Vasculitis 

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References

  1. 1.
    Lillehei RC, Idezuki T, Furnster JA, Dietzman RH, Kelly WD, Merkel FK, et al. Transplantation of stomach, intestine, and pancreas: experimental and clinical observations. Surgery 8. 1967; 62: 721–41.Google Scholar
  2. 2.
    Monchik GJ, Russell PS. Transplantation of small bowel in the rat: technical and immunological considerations. 9. Surgery 1971; 70: 693–702.PubMedGoogle Scholar
  3. 3.
    Todo S, Reyes J, Furukawa H, Abu-Elmagd K, Lee RG, Tzakis A, et al. Outcome analysis of 71 clinical intestinal trans- 10. plantations. Ann Surg 1995; 222: 270–82.PubMedCrossRefGoogle Scholar
  4. 4.
    Williamson RCN, Chir M. Intestinal adaptation. N Engl J Med 1978;298:1393–402, 1444–50. 11.Google Scholar
  5. 5.
    Thompson JS, Langas AN, Pinch LW, Kaufman S, Quigley EM, Vanderhoof JA. Surgical approach to short bowel syndrome. Experience in a population of 160 patients. Ann Surg 1995; 224: 600–5. 12.Google Scholar
  6. 6.
    Howard L, Heaphey L, Fleming CR, et al. Four years of North American Registry home parenteral nutrition outcome data and their implications for patient management. J Parenter Enteral Nutr 1991; 15: 384–93.CrossRefGoogle Scholar
  7. 7.
    Howard L, Malone M. Current status of home parenteral nutrition in the United States. Transplant Proc 1996; 28: 2691–5.PubMedGoogle Scholar
  8. 8.
    Clark CLI, Wood S, Lennard-Jones JE, Liar PA, Wood RFM. Potential small bowel transplant recipients in the United Kingdom. Transplant Proc 1992; 24: 1060.Google Scholar
  9. 9.
    Jaffe BM, Burgos AA, Martinez-Noack M. The use of jejunal transplants to treat a genetic enzyme deficiency. Ann Surg 1996; 223: 649–56.PubMedCrossRefGoogle Scholar
  10. 10.
    Alessiani M, Tzakis A, Todo S, Demetris AJ, Fung JJ, Starzl TE. Assessment of 5 year experience with abdominal organ cluster transplantation. J Am Coll Surg 1995; 180: 1–9.PubMedGoogle Scholar
  11. 11.
    Eyal Z, Manax WG, Block JH, Lillehei RC. Successful in vitro preservation of the small bowel, including maintenance of mucosal integrity with chlorpromazine, hypothermia, and hyperbaric oxygenation. Surgery 1965; 57: 259–68.PubMedGoogle Scholar
  12. 12.
    Tzakis A, Todo S, Reyes J, Nour B, Abu-Elmagd K, Furukawa H, et al. Evolution of surgical techniques in clinical intestinal transplantation. Transplant Proc 1994; 26: 1407–8.PubMedGoogle Scholar
  13. 13.
    Todo S, Tzakis A, Reyes J, Abu-Elmagd K, Furukawa H,Nour B, et al. Small intestinal transplantation in humans with or without the colon. Transplantation 1994; 57: 840–6.PubMedCrossRefGoogle Scholar
  14. 14.
    Reyes J, Tzakis A, Todo S, et al. Nutritional management of intestinal transplant recipients. Transplant Proc 1993; 25: 1200–1.PubMedGoogle Scholar
  15. 15.
    Todo S, Tzakis A, Ebu-Elmagd K. Reyes J, Starzl TE. Current status of intestinal transplant. Adv Surg 1994; 27: 295–316.PubMedGoogle Scholar
  16. 16.
    Asfar S, Zhong R, Grant D. Small bowel transplantation. Surg Clin North Am 1994; 74: 1197–210.PubMedGoogle Scholar
  17. 17.
    Kusne S, Furukawa H, Abu-Elmagd K, Irish W, Rakela J, Rung J, et al. Infectious complications after small bowel transplantation in adults: an update. Transplant Proc 1996; 28: 2761–2.PubMedGoogle Scholar
  18. 18.
    Zhang W, Frankel WL, Singh A, Laitin E, Klurfeld D, Rambeau JL. Improvement of structure and function in orthotopic small bowel transplantation in the rat by glutamine. Transplantation 1993; 56: 512–17.PubMedCrossRefGoogle Scholar
  19. 19.
    Reyes J, Green M, Bueno J, Jabbour N, Malesnek M, Yunis E, et al. Epstein-Barr virus-associated post-transplant lymphoproliferative disease after small intestinal transplantation. Transplant Proc 1996; 28: 2768–9.PubMedGoogle Scholar
  20. 20.
    Grant D. Current results of intestinal transplantation. The International Intestinal Transplant Registry. Lancet 1996; 347: 1801–3.PubMedCrossRefGoogle Scholar
  21. 21.
    Furukawa H, Abu-Elmagd K, Reyes J, Hutson W, TabascoMinguillan J, Lee R, et al. Intestinal transplantation in 31 adults. Transplant Proc 1996; 28: 2753–4.PubMedGoogle Scholar
  22. 22.
    Sarr MG, Hakim NS. Enteric physiology of the transplanted intestine. Austin, TX: R.G. Landes Company, 1994.Google Scholar
  23. 23.
    Sugitani A, Reynolds JE, Todo S. Immunohistochemical study of the enteric nervous system after small bowel transplantation in humans. Dig Dis Sci 1994; 39: 2448–56.PubMedCrossRefGoogle Scholar
  24. 24.
    Sarr MG, Kelly KA. Myoelectric activity of the autotransplanted canine jejunoileum. Gastroenterology 1981; 81: 303–10.PubMedGoogle Scholar
  25. 25.
    Herkes SM, Smith CD, Sarr MG. Jejunal responses to absorptive and secretory stimuli in the neurally isolated jejunum in vivo. Surgery 1994; 116: 576–86.PubMedGoogle Scholar
  26. 26.
    Oishi AJ, Sarr MG. Intestinal transplantation: effects on ileal enteric absorptive physiology. Surgery 1995; 117: 545–53.PubMedCrossRefGoogle Scholar
  27. 27.
    Oishi Aj, Inoue Y, Souba WW, Sarr MG. Alterations in carrier-mediated glutamine transport after a model of canine jejunal autotransplantation. Dig Dis Sci 1996; 41: 1915–24.PubMedCrossRefGoogle Scholar
  28. 28.
    Sarr MG, Siadati MR, Bailey J, Lucas DL, Roddy DR, Duenes JA. Neural isolation of the jejunoileum: effect on tissue morphometry, mucosal disaccharidase activity, and tissue peptide content. J Surg Res 1996; 61: 416–24.PubMedCrossRefGoogle Scholar
  29. 29.
    Foley MD, Inoue Y, Souba WW, Sarr MG. Extrinsic innervation modulates canine jejunal transport of glutamine, alanine, leucine, and glucose. Surgery 1998; 123: 321–3.PubMedCrossRefGoogle Scholar
  30. 30.
    Sarr MG, Duenes JA, Walters AM. Jejunal and ileal absorptive function after a model of canine jejunoileal autotransplantation. J Surg Res 1991; 51: 233–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Goott B. I.illehei RC, Miller FA. Mesenteric lymphatic regeneration after autografts of small bowel in dogs. Surgery 1960; 48: 571–5.PubMedGoogle Scholar
  32. 32.
    Sarna SK. Cyclic motor activity: migrating motor complex: 1985. Gastroenterology 1985; 89: 894–913.PubMedGoogle Scholar
  33. 33.
    Sarr MG, Duenes JA. Early and long-term effects of a model of intestinal autotransplantation on intestinal motor patterns. Surg Gynecol Obstet 1990; 170: 338–46.PubMedGoogle Scholar
  34. 34.
    Van Lier Ribbink JA, Sarr MG, Tanaka M. Neural isolation of the entire canine stomach in vivo: effects on motility. Am J Physiol 1989; 257: G30–G40.Google Scholar
  35. 35.
    Kerlin P, McCafferty GJ, Robinson DW, et al. Function of free jejunal conduit graft in the cervical esophagus. Gastroenterology 1986; 90: 1956–63.PubMedGoogle Scholar
  36. 36.
    Siadati MR, Murr MM, Foley MK, Duenes JA, Steers JL, Sarr MG. In situ neural isolation of the entire canine upper gut: effects on fasting and fed motility patterns. Surgery 1997; 121: 174–81.PubMedCrossRefGoogle Scholar
  37. 37.
    Hutson WR, Putnam PE, Todo S, et al. Gastric and small intestinal motility in humans following small bowel transplantation. Gastroenterology 1993; 104: A525.Google Scholar
  38. 38.
    Gulligan JJ, Furness JB, Costa M. Migration of the myoelectric complex after interruption of the myenteric plexus: intestinal transection and regeneration of enteric nerves in the guinea pig. Gastroenterology 1989; 97: 1135–46.Google Scholar
  39. 39.
    Murr MM, Miller VM, Sarr MG. Contractile properties of enteric smooth muscle after small bowel transplantation in rats. Am J Surg 1996; 171: 212–18.PubMedCrossRefGoogle Scholar
  40. 40.
    Murr MM, Sarr MG. Small bowel transplantation (SBTx): effect on function of non-adrenergic non-cholinergic nerves. J Gastrointest Surg 1997; 1: 439–45.PubMedCrossRefGoogle Scholar
  41. 41.
    Tesi R, Beck R, Lambiase L, Hague S, Flint L, Jaffe B. Living-related small bowel transplantation: donor evaluation and outcome. Transplant Proc 1997; 29: 686–7.PubMedCrossRefGoogle Scholar

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© Springer-Verlag London 2001

Authors and Affiliations

  • Michel M. Murr
  • Michael G. Sarr

There are no affiliations available

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