SMALL-BOWEL TRANSPLANTATION - CURRENT PROGRESS AND CLINICAL-APPLICATION

Total parenteral nutrition (TPN) is used routinely to maintain patient s with the Short Bowel Syndrome (SBS). Until recently, TPN has been th e only available therapeutic modality for patients with SBS. Currently it is the treatment of choice for such individuals and occasionally, when the loss of bowel is extensive, it may be the only way of maintai ning life. Unfortunately, TPN is expensive and markedly restrains an i ndividual's lifestyle. Despite the overall success of TPN, the numerou s risks associated with its use and the many complications of having a n intravenous indwelling for years have served as the stimulus for alt ernative treatments such as small bowel transplantation (SBT). The fir st attempts at small bowel transplantation in clinical medicine were b y Detterling almost 25 years ago. Patient death or graft Loss in these early attempts was caused by the failure to control graft rejection a nd/or the inability to prevent Graft Versus Host Disease (GVHD). A sti mulus for renewed clinical interest in SBT was provided by Starzl et a l in 1988 with a report of prolonged graft survival without graft reje ction or GVHD in a patient who was the recipient of a multivisceral gr aft consisting of the entire small bowel and other abdominal organs. S ince 1964, 78 Small Bowel transplants have been performed in humans. S everal variations of the multivisceral procedure in which the Liver an d the small bowel constitute the major components of the graft were ad opted. The longest survival has been in a child who is still alive wit h a working graft for more than two years, as reported by Goulet from Paris in. 1989. The introduction in SBT of the new immunosuppressive a gent FK 506 has provided results which are superior to those achieved with Cyclosporine A (CsA). This latter observation prompted the Pittsb urgh group to initiate a large series of isolated and composite intest inal grafts. The remarkable results have demonstrated the clinical uti lity of intestinal transplantation. This paper will try to summarize t he history of the smalt bowel transplantation until the end of the yea r 1992, with the current progress in use today.