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      Intestinal transplantation: evolution and current status

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          Abstract

          Despite early disappointments, the three main types of visceral transplantation (isolated intestine, liver intestine, and multivisceral) have evolved into the standard of care for patients with nutritional failure and complex abdominal pathology. Visceral allografts have been assessed in clinical, radiological, endoscopic, and histopathologic studies. Absorptive functions of engrafted intestine have been assessed by body weight, body mass index, and z scores, serum levels of albumin, vitamins, and trace elements, as well as measurements of bone mineral density. Allograft rejection, infection, and renal failure, are the leading causes of death. Additionally, nonfunctional social support and progression of primary disease contribute to mortality rates beyond the fiveand ten-year follow-up landmarks. Remote events, including acute rejection, post-transplant lymphoproliferative disorder, and graft-versus-host-disease were significantly higher in pediatric recipients. Adult recipients experience higher incidences of de novo malignancy, primary disease recurrence, and impaired skeletal health. The leading causes of death are graft failure, complications of therapy, post-transplant lymphoproliferative disorder, progression of primary disease, and others, such as substance abuse, suicide and lack of support. Health status was sustained with successful interventions to treat hypertension, diabetes, osteoporosis, and renal failure. In spite of disease recurrence and long-term immunosuppression-related morbidities, the health status of most survivors has been sustained with successful interventions to treat occurring co-morbidities. With continual improvement in early survival and long-term rehabilitative efficacy, visceral transplantation should be considered a better therapeutic option for patients with severe intestinal failure.

          Translated abstract

          RESUMO Apesar das primeiras decepções, os três principais tipos de transplante visceral (isolado intestino, fígado, intestino, multivisceral) têm evoluído para tornarem-se o tratamento padrão para pacientes com insuficiência nutricional e patologia abdominal complexa. Aloenxertos viscerais foram avaliados em estudos clínicos, radiológicos, endoscópicos e histopatológicos. Funções de absorção do intestino transplantado foram avaliadas através de peso corporal, índice de massa corporal e escores "z", níveis séricos de albumina, vitaminas e oligoelementos, bem como através de medições de densidade mineral óssea. Rejeição de enxerto, infecção e insuficiência renal, são as principais causas de morte. Além disso, apoio social não-funcionante e progressão da doença primária contribuem para as taxas de mortalidade para além dos marcos de acompanhamento de cinco e dez anos. Eventos remotos, incluindo rejeição aguda pós-transplante, desordem linfoproliferativa e doença enxerto-versus-hospedeiro foram significativamente maiores em pacientes pediátricos. Destinatários adultos estão sujeitos a maior incidência de malignidade, com recorrência da doençaprimária e saúde óssea prejudicada. As principais causas de morte são falha do enxerto, complicações da terapia, desordem linfoproliferativa, progressão da doença primária e outros, tais como o abuso de drogas, suicídio e falta de apoio. De um modo geral, o estado de saúde tem sido sustentado com êxito através de intervenções para tratar a hipertensão, diabetes, osteoporose e insuficiência renal. Apesar de recorrência da doença e de morbidades relacionadas com imunossupressão a longo prazo, o estado de saúde da maioria dos sobreviventes tem sido mantido com intervenções bem sucedidas para tratar co-morbidades. Com a melhoria contínua nos índices de sobrevivência inicial ena eficácia de reabilitação a longo prazo, o transplante visceral deve ser considerado como a melhor opção terapêutica para pacientes com insuficiência intestinal grave.

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          Most cited references164

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          Short bowel syndrome and intestinal failure: consensus definitions and overview.

          Short bowel syndrome (SBS)-associated intestinal failure is a highly disabling condition that impairs quality of life and social integration. Although the condition is not uniformly fatal, it might lead to serious, life-threatening complications. The basic goals of medical treatment are to maintain fluid, electrolyte, and nutrient balances and to make appropriate modifications in disease management to avoid side effects. Various definitions have been proposed for SBS and intestinal failure within the medical literature, but many focus on different aspects of the conditions, leading to confusion. In the past, identifying the cause of intestinal failure was of little consequence, because all patients were managed on total parenteral nutrition at home. However, with the recent development of medical therapies such as recombinant growth hormone, octreotide, and glucagon-like peptide-2 analogues and with improvements in small bowel transplantation, many patients can be made nutritionally autonomous. To evaluate the relative efficacy of these therapies, there is now a need to develop consensus definitions so that patients can be properly categorized before therapy. To this end, a group of experts on the subject was convened to develop the following new definitions: "Intestinal failure results from obstruction, dysmotility, surgical resection, congenital defect, or disease-associated loss of absorption and is characterized by the inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance." "Short-bowel syndrome results from surgical resection, congenital defect, or disease-associated loss of absorption and is characterized by the inability to maintain protein-energy, fluid, electrolyte, or micronutrient balances when on a conventionally accepted, normal diet."
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            Intestinal transplantation.

            T Fishbein (2009)
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              Intestinal loop lengthening--a technique for increasing small intestinal length.

              A reproducible technique is described for doubling the length of a loop of small intestine, while simultaneously reducing its luminal diameter, and preserving the maximum amount of small bowel mucosa for intestinal adaptation. In pig experiments, 7 loops have been increased in length by the "intestinal loop lengthening" procedure, with survival of 5 of the 7 animals for a period of 16-26 wk. Leakage from the lengthened intestinal segment led to the death of one animal. At a second operation, or at termination of the experiment, all seven lengthened loops had a good blood supply and were patent along their full length. Histologic examination of 3 of the 4 specimens from the first phase of the study confirmed their viability. The potential application of intestinal loop lengthening in the management of the short gut syndrome is discussed.
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                Author and article information

                Contributors
                Role: ND
                Role: ND
                Journal
                medical
                MedicalExpress
                MedicalExpress (São Paulo, online)
                Mavera Edições Técnicas e Científicas Ltda
                2358-0429
                December 2014
                : 1
                : 6
                : 307-322
                Affiliations
                [1 ] Universidade Federal de Minas Gerais Brazil
                [2 ] University of Pennsylvania United States
                Article
                S2358-04292014000600307
                10.5935/MedicalExpress.2014.06.05
                50179939-64b2-43ce-ada9-97b9eff33f8a

                This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

                History
                Product

                SciELO Brazil

                Self URI (journal page): http://www.scielo.br/scielo.php?script=sci_serial&pid=2358-0429&lng=en
                Categories
                HEALTH CARE SCIENCES & SERVICES

                Health & Social care
                Intestinal transplantation,Gastrointestinal rehabilitation,Multivisceral transplantation

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