SMALL-INTESTINAL TRANSPLANTATION

The management of patients with intestinal failure has benefited from progress in parenteral nutrition (PN), especially home-based PN. Intes tinal transplantation is henceforth possible and appears now, under ce rtain conditions, the logical therapeutic option. Since 1985, more tha n 180 small-bowel grafts have been performed, involving the isolated s mall bo,vel with or without the colon (38 %), the liver plus the small bowel (46 %) or several more organs (16 %). Two thirds of the recipie nts were under 20 years of age, and indications were short-bowel syndr ome (64%), severe intractable diarrhea (13 %), abdominal cancer (13 %) or chronic intestinal pseudo-obstruction syndrome (8 %). Fifty one pe r cent of the patients survived more than two years after graft. Patie nt and graft survival depend on the type of immunosuppression, i.e. Cy A or FK506. The results must be carefully interpreted as they represen t the first experience in numerous centers using different immunosuppr ession protocols, without any randomization. Results obtained in the l argest of these centers are more indicative of the current situation. This article reviews the main aspects of human intestinal transplantat ion with special focus on graft rejection in terms of immunohistochemi cal expression which is decisive for diagnosis and specific treatment. Functional grafts lead to gastrointestinal autonomy (weaning of PN) w hile maintaining satisfactory nutritional status and normal growth in childhood. Intestinal transplantation is theoretically indicated for a ll patients permanently or lengthily dependent on PN. However, as PN i s generally well tolerated, even for long periods, each indication of transplantation must be carefully weighed up in terms of iatrogenic ri sk and quality of life. When PN has reached its limits, especially tho se associated with vascular, infectious, hepatic or metabolic complica tions, intestinal transplantation must be considered. Transplantation of the small bowel alone remains the first option, as combined liver-s mall bowel grafting is indicated only in case of life-threatening prog ressive cirrhogenic liver disease.